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psnet.ahrq.gov/issue/preventing-errors-when-preparing-and-administering-medications-enteral-feeding-tubes
November 30, 2016 - Newspaper/Magazine Article
Preventing errors when preparing and administering medications via enteral feeding tubes.
Citation Text:
Preventing errors when preparing and administering medications via enteral feeding tubes. ISMP Medication Safety Alert! Acute care edition. November 17, 202…
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psnet.ahrq.gov/issue/survey-results-pharmacists-provide-support-enhance-organizational-response-codes
November 02, 2022 - Newspaper/Magazine Article
Survey results from pharmacists provide support to enhance the organizational response to codes.
Citation Text:
Survey results from pharmacists provide support to enhance the organizational response to codes. ISMP Medication Safety Alert! Acute care edition. Oc…
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psnet.ahrq.gov/issue/pharmacy-led-medication-reconciliation-best-practice
September 30, 2020 - Newspaper/Magazine Article
Pharmacy-led medication reconciliation is best practice.
Citation Text:
Pharmacy-led medication reconciliation is best practice. Tanski MC. Pharmacy Times Health Systems edition. September 2023;12(5):34-35.
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psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-they-suggest-carefully-following
February 24, 2016 - Newspaper/Magazine Article
Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors.
Citation Text:
Government and industry fail to protect the public when they suggest "carefully following instructions" i…
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psnet.ahrq.gov/issue/administration-concentrated-potassium-chloride-injection-during-code-still-deadly
May 02, 2018 - Newspaper/Magazine Article
Administration of concentrated potassium chloride for injection during a code: still deadly!
Citation Text:
Administration of concentrated potassium chloride for injection during a code: still deadly! ISMP Medication Safety Alert! Acute care edition. June …
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psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful
August 21, 2019 - Newspaper/Magazine Article
When medical error becomes personal, activism becomes painful.
Citation Text:
When medical error becomes personal, activism becomes painful. Millenson M. Forbes. September 16, 2022.
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psnet.ahrq.gov/issue/incident-learning-radiation-oncology-review
October 14, 2020 - Review
Emerging Classic
Incident learning in radiation oncology: a review.
Citation Text:
Ford E, Evans SB. Incident learning in radiation oncology: A review. Med Phys. 2018;45(5):e100-e119. doi:10.1002/mp.12800.
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psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
April 26, 2023 - provide timely indication of changes in patient state (e.g., via oxygen saturation, pulse rate, and other indicators
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - SPOTLIGHT CASE
Transfusion Thresholds in Gastrointestinal Bleeding
Citation Text:
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
March 07, 2012 - Liver Biopsy: Proceed With Caution
Citation Text:
Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - SPOTLIGHT CASE
Double Trouble
Citation Text:
Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Spotlight
Missed Opportunities for Suicide
Risk Assessment
Source and Credits
• This presentation is based on the November 2019 AHRQ WebM&M
Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Glen Xiong, MD & Debra Kahn, MD
○ Editors in Chief, AHRQ We…
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psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
June 24, 2010 - Methicillin-Resistant Staphylococcus aureus
Gary A. Noskin, MD | April 1, 2008
View more articles from the same authors.
Citation Text:
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
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psnet.ahrq.gov/node/49402/psn-pdf
June 01, 2003 - Inappropriate Antibiotic Use
June 1, 2003
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
The Case
A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a
first presentation of s…
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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psnet.ahrq.gov/node/49600/psn-pdf
April 01, 2010 - Bad Writing, Wrong Medication
April 1, 2010
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
Case Objectives
Differentiate between a medication error and an adverse drug event.
Appreciate the system complexities involved in medication erro…
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - Pseudo-obstruction But a Real Perforation
July 1, 2017
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
Case Objectives
Recognize acute colonic pseudo-obstruction and implement a medical management plan.
Ide…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
January 01, 2024 - The Different Count Contributions to Retention
Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty
Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1
Enforcement Reports from 2007-2014
A NoThing Left Behin…
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psnet.ahrq.gov/node/33807/psn-pdf
May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD
May 1, 2016
In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
Editor's note: Dr. Drew, a nurse researcher, is the David Mortara Distinguished Professor of Physiological
Nursing and…