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psnet.ahrq.gov/node/45535/psn-pdf
January 23, 2017 - Surgical specimen management: a descriptive study of
648 adverse events and near misses.
January 23, 2017
Steelman VM, Williams TL, Szekendi MK, et al. Surgical specimen management: a descriptive study of 648
adverse events and near misses. Arch Pathol Lab Med. 2016;140(12):1390-1396.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/60342/psn-pdf
May 20, 2020 - Occurrence, prevention, and management of the
psychological effects of emerging virus outbreaks on
healthcare workers: rapid review and meta-analysis.
May 20, 2020
Kisely S, Warren N, McMahon L, et al. Occurrence, prevention, and management of the psychological
effects of emerging virus outbreaks on healthcare wor…
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psnet.ahrq.gov/node/36148/psn-pdf
March 03, 2011 - Surgical crisis management skills training and
assessment: a stimulation-based approach to enhancing
operating room performance.
March 3, 2011
Moorthy K, Munz Y, Forrest D, et al. Surgical Crisis Management Skills Training and Assessment. Ann
Surg. 2006;244(1). doi:10.1097/01.sla.0000217618.30744.61.
https://psne…
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psnet.ahrq.gov/node/39262/psn-pdf
March 04, 2011 - Unintended errors with EHR-based result management: a
case series.
March 4, 2011
Yackel TR, Embi P. Unintended errors with EHR-based result management: a case series. J Am Med
Inform Assoc. 2010;17(1):104-7. doi:10.1197/jamia.M3294.
https://psnet.ahrq.gov/issue/unintended-errors-ehr-based-result-management-case-se…
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psnet.ahrq.gov/node/37957/psn-pdf
August 06, 2008 - Surgical management and outcomes of 165 colonoscopic
perforations from a single institution.
August 6, 2008
Iqbal CW, Cullinane DC, Schiller HJ, et al. Surgical management and outcomes of 165 colonoscopic
perforations from a single institution. Arch Surg. 2008;143(7):701-6; discussion 706-7.
doi:10.1001/archsurg.1…
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psnet.ahrq.gov/node/42183/psn-pdf
November 25, 2013 - Electronic prescribing in pediatrics: toward safer and
more effective medication management.
November 25, 2013
Committee 2011–2012 AA of PC on CITE. Electronic prescribing in pediatrics: toward safer and more
effective medication management. Pediatrics. 2013;131(4):824-6. doi:10.1542/peds.2013-0192.
https://psnet.…
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psnet.ahrq.gov/node/36771/psn-pdf
January 22, 2017 - A pediatric medical emergency team manages a complex
child with hypoxia and a worried parent.
January 22, 2017
Shilkofski NA, Hunt EA. A pediatric medical emergency team manages a complex child with hypoxia and
worried parent. Jt Comm J Qual Patient Saf. 2007;33(4):236-41, 185.
https://psnet.ahrq.gov/issue/pediatr…
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psnet.ahrq.gov/node/47214/psn-pdf
June 20, 2018 - Journal of Patient Safety and Risk Management.
June 20, 2018
Wu AW, ed. Thousand Oaks, CA: SAGE Publications. ISSN: 2516-0435.
https://psnet.ahrq.gov/issue/journal-patient-safety-and-risk-management
Risk management and legal issues can affect safety responses throughout a health care system. Articles in
this publi…
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psnet.ahrq.gov/node/39626/psn-pdf
June 23, 2010 - The Medication Manager: results of a medication at the
bedside pilot in a pediatric teaching institution.
June 23, 2010
Wagner D, Pasko D, Glenn D, et al. The Medication Manager. J Patient Saf. 2010;6(2).
doi:10.1097/pts.0b013e3181cb43b4.
https://psnet.ahrq.gov/issue/medication-manager-results-medication-bedside-p…
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psnet.ahrq.gov/node/49758/psn-pdf
April 01, 2016 - Dropping to New Lows
April 1, 2016
Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/dropping-new-lows
Case Objectives
State how to manage diabetes medications when patients are admitted to the hospital
Describe a guideline-recommended insulin regimen for a hospitaliz…
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psnet.ahrq.gov/node/35719/psn-pdf
April 12, 2011 - Risk management, or just a different risk: a national
survey of newborn units following a patient safety alert.
April 12, 2011
Freer Y. Risk management, or just a different risk? Archives of Disease in Childhood - Fetal and Neonatal
Edition. 2006;91(5). doi:10.1136/adc.2005.089540.
https://psnet.ahrq.gov/issue/ris…
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psnet.ahrq.gov/node/35482/psn-pdf
May 27, 2011 - The introduction of computerized physician order entry
and change management in a tertiary pediatric hospital.
May 27, 2011
Upperman JS, Staley P, Friend K, et al. The introduction of computerized physician order entry and change
management in a tertiary pediatric hospital. Pediatrics. 2005;116(5):e634-42.
https:/…
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psnet.ahrq.gov/node/41880/psn-pdf
January 08, 2014 - DOD and VA Health Care: Medication Needs During
Transitions May Not Be Managed for All Servicemembers.
January 8, 2014
Washington, DC: United States Government Accountability Office; November 2, 2012. Publication GAO-13-
26.
https://psnet.ahrq.gov/issue/dod-and-va-health-care-medication-needs-during-transit…
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psnet.ahrq.gov/node/36859/psn-pdf
May 11, 2014 - High-risk, high-alert medication management practices in
a regional state psychiatric facility.
May 11, 2014
McKee J, Cleary S. High-Risk, High-Alert Medication Management Practices in a Regional State
Psychiatric Facility. Hosp Pharm. 2007;42(4):323-330. doi:10.1310/hpj4204-323.
https://psnet.ahrq.gov/issue/high-…
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psnet.ahrq.gov/node/44279/psn-pdf
August 26, 2015 - Leadership style and patient safety: implications for
nurse managers.
August 26, 2015
Merrill KC. Leadership style and patient safety: implications for nurse managers. J Nurs Adm.
2015;45(6):319-324. doi:10.1097/NNA.0000000000000207.
https://psnet.ahrq.gov/issue/leadership-style-and-patient-safety-implications-nur…
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psnet.ahrq.gov/node/41134/psn-pdf
July 06, 2012 - Differential impact of a crew resource management
program according to professional specialty.
July 6, 2012
Suva D, Haller G, Lübbeke A, et al. Differential impact of a crew resource management program according
to professional specialty. Am J Med Qual. 2012;27(4):313-20. doi:10.1177/1062860611423805.
https://psne…
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psnet.ahrq.gov/node/35178/psn-pdf
April 23, 2014 - Computer visualisation of patient safety in primary care: a
systems approach adapted from management science
and engineering.
April 23, 2014
Singh R, Singh A, Fox C, et al. Computer visualisation of patient safety in primary care: a systems
approach adapted from management science and engineering. Inform Prim Care…
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psnet.ahrq.gov/node/44223/psn-pdf
November 22, 2016 - Patient Safety and Incident Management Toolkit.
November 22, 2016
Edmonton, AB: Canadian Patient Safety Institute. June 2015.
https://psnet.ahrq.gov/issue/patient-safety-and-incident-management-toolkit
Engaging patients and families in safety can uncover concerns and inform improvement efforts. This three-
compone…
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psnet.ahrq.gov/node/38279/psn-pdf
April 09, 2009 - Quality management and patient safety: survey results
from 102 Hungarian hospitals.
April 9, 2009
Makai P, Klazinga NS, Wagner C, et al. Quality management and patient safety: survey results from 102
Hungarian hospitals. Health Policy (New York). 2009;90(2-3):175-80. doi:10.1016/j.healthpol.2008.09.009.
https://ps…
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psnet.ahrq.gov/node/42768/psn-pdf
November 27, 2013 - Findings and Lessons From the Improving Management
of Individuals With Complex Health Care Needs Through
Health IT Grant Initiative.
November 27, 2013
Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-
0058-EF.
https://psnet.ahrq.gov/issue/findings-and-lesso…