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2381. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40738/psn-pdf
      June 10, 2018 - Misadministration of IV insulin associated with dose measurement and hyperkalemia treatment. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. August 11, 2011;16:1-3. https://psnet.ahrq.gov/issue/misadministration-iv-insulin-associated-dose-measurement-and-hyperkalemia- treatment This article discus…

2382. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40518/psn-pdf
      June 15, 2011 - Consensus building for development of outpatient adverse drug event triggers. June 15, 2011 Mull HJ, Nebeker JR, Shimada SL, et al. Consensus building for development of outpatient adverse drug event triggers. J Patient Saf. 2011;7(2):66-71. doi:10.1097/PTS.0b013e31820c98ba. https://psnet.ahrq.gov/issue/consensus-…

2383. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49614/psn-pdf
      November 01, 2010 - Reconciling Records November 1, 2010 Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/reconciling-records The Cases   Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local teaching hospital. When discharged, h…

2384. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
      December 01, 2013 - PowerPoint Presentation Spotlight Case New Oral Anticoagulants 1 This presentation is based on the December 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Margaret C. Fang, MD, MPH, University of California, San Francisco Editor, AHRQ WebM&M…

2385. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38550/psn-pdf
      May 08, 2018 - Fatal outcome after inadvertent injection of topical epinephrine. May 8, 2018 ISMP Medication Safety Alert! Acute Care Edition. March 26, 2009;14:1-2. https://psnet.ahrq.gov/issue/fatal-outcome-after-inadvertent-injection-topical-epinephrine This article reports on the mistaken administration of a high-alert medic…

2386. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36982/psn-pdf
      June 11, 2017 - Requires DHSS to make reported information about certain adverse events publicly available. June 27, 2007 212 New Jersey Legislature. Assembly, No. 4327. June 11, 2017. https://psnet.ahrq.gov/issue/requires-dhss-make-reported-information-about-certain-adverse-events- publicly-available This bill amends a previous…

2387. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40089/psn-pdf
      July 27, 2011 - Serious Reportable Events July 27, 2011 National Quality Forum. 2009-2011. https://psnet.ahrq.gov/issue/patient-safety-serious-reportable-events-healthcare This project--now complete--examined the presence and tracking of never events as part of a larger National Quality Forum strategy to improve patient safety. T…

2388. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43443/psn-pdf
      August 13, 2014 - Feds stop public disclosure of many serious hospital errors. August 13, 2014 O'Donnell J. https://psnet.ahrq.gov/issue/feds-stop-public-disclosure-many-serious-hospital-errors This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site. Several avoidable hospital-acquired …

2389. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49779/psn-pdf
      January 01, 2017 - The Empty Bag December 1, 2016 Vincent C. The Empty Bag. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/empty-bag The Case A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a hip fracture after a fall at a nursing home. During the hospitalization, her kidne…

2390. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.101_slideshow.ppt
      July 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case July 2005 Impatient Inpatient Dosing Source and Credits This presentation is based on the July 2005 AHRQ WebM&M Spotlight Case in Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Richard H. White…

2391. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34728/psn-pdf
      December 19, 2016 - Forgive and Remember: Managing Medical Failure. 2nd ed. December 19, 2016 Bosk CL.Chicago, IL: University of Chicago Press; 2003. ISBN: 9780226066783. https://psnet.ahrq.gov/issue/forgive-and-remember-managing-medical-failure-2nd-ed In this seminal study, Bosk, a medical sociologist at the University of Pennsylvan…

2392. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43293/psn-pdf
      June 25, 2014 - Health-care providers want patients to read medical records, spot errors. June 25, 2014 Landro L. Wall Street Journal. June 9, 2014. https://psnet.ahrq.gov/issue/health-care-providers-want-patients-read-medical-records-spot-errors As they become more prevalent, electronic medical records (EMRs) are being used to i…

2393. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41932/psn-pdf
      December 19, 2012 - Important change to heparin container labels to clearly state the total drug strength. December 19, 2012 MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 6, 2012. https://psnet.ahrq.gov/issue/important-change-heparin-container-labels-clearly-state-total-drug-strength This announc…

2394. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46408/psn-pdf
      November 29, 2017 - Eliminating vincristine administration events. November 29, 2017 Quick Safety. October 16, 2017;(37):1-3. https://psnet.ahrq.gov/issue/eliminating-vincristine-administration-events Vincristine administration errors can have serious consequences. This newsletter article outlines steps to reduce risks associated wit…

2395. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42537/psn-pdf
      October 02, 2013 - The use of a checklist in a pediatric oncology clinic. October 2, 2013 McLean TW, White GM, Bagliani AF, et al. The use of a checklist in a pediatric oncology clinic. Pediatr Blood Cancer. 2013;60(11):1855-9. doi:10.1002/pbc.24657. https://psnet.ahrq.gov/issue/use-checklist-pediatric-oncology-clinic An Institute o…

2396. Primary Care and Patient Safety: Opportunities at the Interface | PSNet
      psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
      September 28, 2022 - Primary Care and Patient Safety: Opportunities at the Interface September 28, 2022  Also Read the Conversations In Conversation With... Freya Spielberg, MD, MPH In Conversation With... Jack Westfall, MD, MPH View more articles from the same authors. …