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psnet.ahrq.gov/issue/how-create-my-medicines-list
December 24, 2008 - Tools/Toolkit
How To Create a My Medicines List.
Citation Text:
How To Create a My Medicines List. Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - Another example is around medication lists: who can touch them, how should they be kept accurate, what
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. 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/harm-alarm-fatigue
February 14, 2018 - SPOTLIGHT CASE
Harm From Alarm Fatigue
Citation Text:
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue
Citation Text:
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. 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/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure?
October 1, 2008
Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
Case Objectives
Understand the complementary abilities of an electronic health record a…
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psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease
Citation Text:
Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride
Extravasation.
April 26, 2023
The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
The Case
A 52-year-old man with a history of lymphoplasmacytic lymph…
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psnet.ahrq.gov/node/33738/psn-pdf
December 01, 2012 - In Conversation With... John G. Reiling, PhD
December 1, 2012
In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with
hospitals and…
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psnet.ahrq.gov/node/853773/psn-pdf
September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side.
September 27, 2023
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
The Case
A first-year orthopedic surgery resident was consulted…
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psnet.ahrq.gov/node/49516/psn-pdf
August 01, 2006 - Physical Diagnosis: A Lost Art?
August 1, 2006
Thompson GR, Verghese A. Physical Diagnosis: A Lost Art? PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
Case Objectives
Appreciate the decline in proficiency and reliance on physical examination skills among health care
providers.
…
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psnet.ahrq.gov/node/33885/psn-pdf
August 01, 2019 - In Conversation With… Susan Smith, MD
August 1, 2019
In Conversation With… Susan Smith, MD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-smith-md
Editor's note: Dr. Smith, a family medicine physician, is chief faculty practices officer for UCSF Health.
Over the past 3–4 years, the …
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psnet.ahrq.gov/node/33801/psn-pdf
February 01, 2016 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
Editor's note: Christine A. Sinsky, MD, is the Vice President for Professional Satisfaction at the American
Me…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - hospitals have worked with ambulance staff to remind them to pick up prescription bottles or medication
lists … Individually, patients should be encouraged
to carry their medication lists and present them at each
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psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - CVP, thereby decreasing the pressure
gradient that promotes air embolism formation.(5,8,9) The Table lists … risks, while CVC removal has not.(11) Based on this bias, CVC insertion has long been included in lists
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - setting, providers
should review with the patient and/or responsible family member previous medication lists … setting, providers should review with the patient and/or responsible family member previous
medication lists
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psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - The FDA also has a website that lists all current REMS drugs, and FDA-approved prescribing information … Table 2 lists several safety systems that can be considered.( 8 ) Some of the strategies focus on individuals
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Similar to the Armor study, this one found discrepancies between hospital discharge and home medication lists … Both studies indicate that creating a new approach to reconciling patients' discharge medication lists
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - setting, providers should review with the patient and/or responsible family member previous medication lists … setting, providers should review with the patient and/or responsible family member previous medication lists