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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - SPOTLIGHT CASE
The Other Side
Citation Text:
Vincent CA. The Other Side. 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/web-mm/when-indications-drug-administration-blur
May 26, 2021 - SPOTLIGHT CASE
When the Indications for Drug Administration Blur
Citation Text:
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - SPOTLIGHT CASE
Discharge Fumbles
Citation Text:
Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - Eptifibatide Epilogue
Citation Text:
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - SPOTLIGHT CASE
Missed Appendicitis
Citation Text:
Adams JG. Missed Appendicitis. 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/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
Citation Text:
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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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/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/861880/psn-pdf
January 31, 2024 - Patient and Family Centered I-PASS (Family-Centered
Communication Program to Reduce Medical Errors and
Improve Family Experience and Communication
Processes)
January 31, 2024
https://psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-
program-reduce-medical
Summary
Medica…
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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/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/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/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/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/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/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/node/49660/psn-pdf
August 01, 2012 - that require urgent attention
• Presenting results in the context of previous results, medication lists … , and problem lists
• Forwarding capability and allowing the use of surrogates during planned absences