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psnet.ahrq.gov/issue/do-no-harm-novel-safety-checklist-and-research-approach-determine-whether-launch-artificial
September 23, 2020 - Commentary
A "Do No Harm" novel safety checklist and research approach to determine whether to launch an artificial intelligence-based medical technology: introducing the Biological-Psychological, Economic, and Social (BPES) Framework.
Citation Text:
Khan WU, Seto E. "Do No Harm" novel s…
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psnet.ahrq.gov/issue/safety-cases-digital-health-innovations-can-they-work
April 13, 2022 - Commentary
Safety cases for digital health innovations: can they work?
Citation Text:
Sujan M, Habli I. Safety cases for digital health innovations: can they work? BMJ Qual Saf. 2021;30(12):1047-1050. doi:10.1136/bmjqs-2021-012983.
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psnet.ahrq.gov/issue/medical-line-entanglement-unspoken-patient-safety-hazard-medical-devices
May 08, 2019 - Study
Medical line entanglement: the unspoken patient safety hazard of medical devices.
Citation Text:
Larimer C, Sumner V, Wander D. Medical line entanglement: the unspoken patient safety hazard of medical devices. Nutr Clin Pract. 2023;38(6):1296-1308. doi:10.1002/ncp.11000.
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psnet.ahrq.gov/issue/usage-and-accuracy-medication-data-nationwide-health-information-exchange-quebec-canada
June 17, 2020 - Study
Usage and accuracy of medication data from nationwide health information exchange in Quebec, Canada.
Citation Text:
Motulsky A, Weir DL, Couture I, et al. Usage and accuracy of medication data from nationwide health information exchange in Quebec, Canada. J Am Med Inform Assoc. 201…
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psnet.ahrq.gov/issue/examining-medication-ordering-errors-using-ahrq-network-patient-safety-databases
November 30, 2022 - Study
Examining medication ordering errors using AHRQ Network of Patient Safety Databases.
Citation Text:
Grauer A, Rosen A, Applebaum JR, et al. Examining medication ordering errors using AHRQ network of patient safety databases. J Am Med Inform Assoc. 2023;30(5):838-845. doi:10.1093/ja…
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - Also, as in most hospitals, the nursing medication administration record (MAR) listed the once-daily
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psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - Medication Errors and Adverse Drug Events
December 15, 2024
Medication Errors and Adverse Drug Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect cu…
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psnet.ahrq.gov/issue/identifying-high-alert-medications-university-hospital-applying-data-medication-error
August 03, 2017 - Study
Identifying high-alert medications in a university hospital by applying data from the medication error reporting system.
Citation Text:
Tyynismaa L, Honkala A, Airaksinen M, et al. Identifying High-alert Medications in a University Hospital by Applying Data From the Medication Erro…
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psnet.ahrq.gov/issue/building-bridge-quality-urgent-call-integrate-quality-improvement-and-patient-safety
January 14, 2014 - Commentary
Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care
Citation Text:
Wong BM, Baum KD, Headrick LA, et al. Building the bridge to quality: an urgent call to integrate quality improvement and patient safe…
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psnet.ahrq.gov/issue/high-alert-medications-pediatric-intensive-care-unit
December 16, 2015 - Study
High-alert medications in the pediatric intensive care unit.
Citation Text:
Franke HA, Woods D, Holl JL. High-alert medications in the pediatric intensive care unit. Pediatr Crit Care Med. 2009;10(1):85-90. doi:10.1097/PCC.0b013e3181936ff8.
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psnet.ahrq.gov/issue/standardized-assessment-medication-reconciliation-post-acute-care
December 16, 2020 - Study
Standardized assessment of medication reconciliation in post-acute care.
Citation Text:
Fischer SH, Shih RA, McMullen TL, et al. Standardized assessment of medication reconciliation in post‐acute care. J Am Geriatr Soc. 2022;70(4):1047-1056. doi:10.1111/jgs.17655.
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psnet.ahrq.gov/issue/examples-medical-device-misconnections
March 04, 2015 - Multi-use Website
Examples of Medical Device Misconnections.
Citation Text:
Examples of Medical Device Misconnections. Food and Drug Administration. February 23. 2023.
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psnet.ahrq.gov/issue/fda-urged-move-faster-fix-pulse-oximeters-darker-skinned-patients
September 21, 2016 - Newspaper/Magazine Article
FDA urged to move faster to fix pulse oximeters for darker-skinned patients.
Citation Text:
FDA urged to move faster to fix pulse oximeters for darker-skinned patients. McFarling UL. STAT. February 2, 2024.
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psnet.ahrq.gov/issue/anatomy-medical-device-recall-how-defective-products-can-slip-through-outdated-system
December 03, 2014 - Newspaper/Magazine Article
Anatomy of a medical device recall: how defective products can slip through an outdated system.
Citation Text:
Anatomy of a medical device recall: how defective products can slip through an outdated system. Zipp R. Medical Tech Dive. October 18, 2021.
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psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-months-shutdown-then
July 18, 2018 - Newspaper/Magazine Article
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go.
Citation Text:
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. Massey W, Keith …
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psnet.ahrq.gov/issue/drawn-curtains-muted-alarms-and-diverted-attention-lead-tragedy-postanesthesia-care-unit
June 10, 2018 - Newspaper/Magazine Article
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.
Citation Text:
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit. ISMP Medication Safety Alert! Acute Care E…
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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/web-mm/missed-patient-assignment-anyone-there
September 01, 2017 - Missed Patient Assignment: Is Anyone There?
Citation Text:
Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - Slow Down: Right Drug, Wrong Formulation
Citation Text:
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. 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/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - CYP450 Drugs: Expect the Unexpected
Citation Text:
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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