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psnet.ahrq.gov/issue/contributions-tele-intensive-care-unit-tele-icu-technology-quality-care-and-patient-safety
February 16, 2022 - Study
Contributions of tele-intensive care unit (tele-ICU) technology to quality of care and patient safety.
Citation Text:
Khunlertkit A, Carayon P. Contributions of tele-intensive care unit (Tele-ICU) technology to quality of care and patient safety. J Crit Care. 2013;28(3):315.e1-12…
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psnet.ahrq.gov/node/49866/psn-pdf
June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the
Operating Room
June 1, 2019
Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
The Case
A 43-year-old woman was admi…
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psnet.ahrq.gov/node/33824/psn-pdf
January 01, 2016 - Patient Safety and Opioid Medications
January 1, 2016
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
Annual Perspective 2016
Opioid medications confer significant risks of harm, including overdose death …
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Annual Perspective
Computerized Provider Order Entry and Patient Safety
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…
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psnet.ahrq.gov/node/33761/psn-pdf
February 01, 2014 - Interruptions and Distractions in Health Care: Improved
Safety With Mindfulness
February 1, 2014
Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet
[internet]. 2014.
https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…
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psnet.ahrq.gov/web-mm/lap-burn
March 01, 2018 - Lap Burn
Citation Text:
Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Cita…
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psnet.ahrq.gov/node/867845/psn-pdf
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step
Technique Innovation Summary
February 26, 2025
https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-
summary
Summary
This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
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psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis
Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008
View more articles from the same authors.
Citation Text:
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …
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psnet.ahrq.gov/node/33631/psn-pdf
April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to
Promote a Culture of Safety
April 1, 2006
Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a
Culture of Safety. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…
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psnet.ahrq.gov/node/49634/psn-pdf
September 01, 2011 - Situational (Un)Awareness
September 1, 2011
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/situational-unawareness
The Case
A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver
function tests, including a bi…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
August 01, 2015 - PowerPoint Presentation
Spotlight
Privacy or Safety?
1
This presentation is based on the July/August 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John D. Halamka, MD, MS, Beth Israel Deaconess Medical Center; and Deven McGraw, JD, MPH, LLM…
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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Mixup Beyond the Medication Label
August 1, 2018
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
The Case
An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another
hospi…
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psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - Workaround Error
February 1, 2006
Pape T. Workaround Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/workaround-error
The Case
A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with
pneumonia and congestive heart failure (CHF). After his acute hospita…
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psnet.ahrq.gov/node/49520/psn-pdf
September 01, 2006 - DNR in the OR and Afterwards
September 1, 2006
Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
The Case
An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and
suffered a fractured femur. After initial eval…
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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - Feeling No Pain
July 1, 2003
Bogner MS. Feeling No Pain. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/feeling-no-pain
The Case
A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the
patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - Chemotherapy Administration Safety Standards
September 1, 2018
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
The Case
A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…
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psnet.ahrq.gov/node/33850/psn-pdf
January 01, 2018 - EHR Copy and Paste and Patient Safety
January 1, 2018
Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
Perspective
Although the ability to copy and paste text is a central benefit of computing in general, and electronic…
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psnet.ahrq.gov/node/49469/psn-pdf
December 01, 2004 - Overriding Considerations
December 1, 2004
Holtzman NA. Overriding Considerations. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/overriding-considerations
The Case
Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic
testing for a variety of condition…
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Is the Admission Drug Dose Too Low?
August 1, 2009
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
The Case
A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to
the hospit…