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psnet.ahrq.gov/node/49788/psn-pdf
March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A
Pharmacist Intervention
March 1, 2017
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
The Case
A 48-year…
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Chemotherapy Administration Safety Standards
Citation Text:
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat
Hyponatremia
January 29, 2020
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet].
2020.
https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
The Case
A 54-year-old man was brought t…
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - Toxic Tachycardia
Citation Text:
Wartofsky L. Toxic Tachycardia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/hazards-loading-doses
December 01, 2003 - Hazards of Loading Doses
Citation Text:
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. 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/node/49479/psn-pdf
April 01, 2005 - The Forgotten Med
April 1, 2005
Cucina R. The Forgotten Med. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/forgotten-med
The Case
A 78-year-old woman with a history of chronic obstructive pulmonary disease (COPD) came to the hospital
with increasing shortness of breath and chest pain. Although she had no …
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psnet.ahrq.gov/node/49680/psn-pdf
March 01, 2013 - Pathologic Mistake
March 1, 2013
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/pathologic-mistake
The Case
A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The
discomfort worsened with eating. After losing 15 pounds …
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - Risk Management and Patient Safety
December 1, 2010
Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety
Perspective
In 1990, a Harvard-based research team reported the incidence of medical errors …
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psnet.ahrq.gov/node/49601/psn-pdf
April 01, 2010 - Nosy Business
April 1, 2010
Orlandi RR. Nosy Business. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/nosy-business
The Case
A 59-year-old man with a history of idiopathic thrombocytopenic purpura (ITP) presented to the emergency
department (ED) with epistaxis (a "nose bleed"). He reported no previous h…
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psnet.ahrq.gov/web-mm/which-end-which
February 09, 2011 - Which End Is Which?
Citation Text:
Campbell AR. Which End Is Which?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/43857/psn-pdf
August 02, 2015 - A checklist-based intervention to improve surgical
outcomes in Michigan: evaluation of the Keystone
Surgery program.
August 2, 2015
Reames BN, Krell RW, Campbell D, et al. A checklist-based intervention to improve surgical outcomes in
Michigan: evaluation of the Keystone Surgery program. JAMA Surg. 2015;150(3):208…
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psnet.ahrq.gov/node/41451/psn-pdf
October 19, 2012 - Challenges of making a diagnosis in the outpatient
setting: a multi-site survey of primary care physicians.
October 19, 2012
Sarkar U, Bonacum D, Strull W, et al. Challenges of making a diagnosis in the outpatient setting: a multi-
site survey of primary care physicians. BMJ Qual Saf. 2012;21(8):641-648. doi:10.113…
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psnet.ahrq.gov/node/39084/psn-pdf
March 05, 2010 - The impact of Rapid Response System on delayed
emergency team activation patient characteristics and
outcomes—a follow-up study.
March 5, 2010
Calzavacca P, Licari E, Tee A, et al. The impact of Rapid Response System on delayed emergency team
activation patient characteristics and outcomes--a follow-up study. Resu…
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psnet.ahrq.gov/node/47559/psn-pdf
November 14, 2018 - Changes in prevalence of health care-associated
infections in U.S. hospitals.
November 14, 2018
Magill SS, O'Leary E, Janelle SJ, et al. Changes in Prevalence of Health Care-Associated Infections in U.S.
Hospitals. N Engl J Med. 2018;379(18):1732-1744. doi:10.1056/NEJMoa1801550.
https://psnet.ahrq.gov/issue/change…
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psnet.ahrq.gov/issue/pressing-better-quality-across-healthcare
July 14, 2010 - Newspaper/Magazine Article
Pressing for better quality across healthcare.
Citation Text:
Pressing for better quality across healthcare. Levey NN.
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psnet.ahrq.gov/node/46893/psn-pdf
March 21, 2018 - Vital signs: trends in emergency department visits for
suspected opioid overdoses- United States, July 2016-
September 2017.
March 21, 2018
Vivolo-Kantor AM, Seth P, Gladden M, et al. Vital Signs: Trends in Emergency Department Visits for
Suspected Opioid Overdoses - United States, July 2016-September 2017. MMWR M…
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psnet.ahrq.gov/node/40965/psn-pdf
December 15, 2011 - Medication errors during patient transitions into nursing
homes: characteristics and association with patient harm.
December 15, 2011
Desai R, Williams CE, Greene SB, et al. Medication errors during patient transitions into nursing homes:
characteristics and association with patient harm. Am J Geriatr Pharmacother.…
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psnet.ahrq.gov/node/47082/psn-pdf
July 02, 2019 - Effect of systematic physician cross-checking on
reducing adverse events in the emergency department:
the CHARMED cluster randomized trial.
July 2, 2019
Freund Y, Goulet H, Leblanc J, et al. Effect of Systematic Physician Cross-checking on Reducing Adverse
Events in the Emergency Department: The CHARMED Cluster Ra…
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psnet.ahrq.gov/node/43817/psn-pdf
November 23, 2016 - Developing and evaluating the success of a family
activated medical emergency team: a quality
improvement report.
November 23, 2016
Brady PW, Zix J, Brilli RJ, et al. Developing and evaluating the success of a family activated medical
emergency team: a quality improvement report. BMJ Qual Saf. 2015;24(3):203-211. …
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psnet.ahrq.gov/node/39948/psn-pdf
December 21, 2014 - Wrong-site and wrong-patient procedures in the Universal
Protocol era: analysis of a prospective database of
physician self-reported occurrences.
December 21, 2014
Stahel PF, Sabel A, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the universal protocol
era: analysis of a prospective database of p…