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  1. psnet.ahrq.gov/issue/implementing-aorn-recommended-practices-prevention-retained-surgical-items
    January 05, 2017 - Commentary Implementing AORN recommended practices for prevention of retained surgical items. Citation Text: Goldberg JL, Feldman DL. Implementing AORN recommended practices for prevention of retained surgical items. AORN J. 2012;95(2):205-16; quiz 217-9. doi:10.1016/j.aorn.2011.11.010…
  2. psnet.ahrq.gov/issue/medication-safety-officers-handbook
    September 01, 2018 - Book/Report Medication Safety Officer's Handbook. Citation Text: Medication Safety Officer's Handbook. Larson CM, Saine D, eds. Bethesda, MD: American Society of Health-System Pharmacists; 2013. ISBN: 9781585282104. Copy Citation Save Save to your library Pr…
  3. psnet.ahrq.gov/issue/updated-guidance-needed-longstanding-large-volume-parenteral-lvp-labeling-and-packaging
    March 10, 2021 - Newspaper/Magazine Article Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. Citation Text: Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. ISMP Medication Safety Alert! Acute ca…
  4. psnet.ahrq.gov/issue/administration-concentrated-potassium-chloride-injection-during-code-still-deadly
    May 02, 2018 - Newspaper/Magazine Article Administration of concentrated potassium chloride for injection during a code: still deadly! Citation Text: Administration of concentrated potassium chloride for injection during a code: still deadly! ISMP Medication Safety Alert! Acute care edition. June …
  5. psnet.ahrq.gov/issue/cognitive-biases-associated-medical-decisions-systematic-review
    March 01, 2023 - Review Cognitive biases associated with medical decisions: a systematic review. Citation Text: Saposnik G, Redelmeier DA, Ruff CC, et al. Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak. 2016;16(1):138. Copy Citation Format: …
  6. psnet.ahrq.gov/issue/coronavirus-commission-safety-and-quality-nursing-homes
    May 26, 2021 - Book/Report Coronavirus Commission for Safety and Quality in Nursing Homes. Citation Text: Coronavirus Commission for Safety and Quality in Nursing Homes. Centers for Medicare and Medicaid Services. McLean, VA: MITRE Corporation; September 2020. Copy Citation …
  7. psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
    February 24, 2022 - errors (e.g., leaving cement in the sulcus), can all jeopardize patient safety and quality of care. 66 Managing
  8. psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
    April 27, 2022 - SPOTLIGHT CASE Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome Citation Text: Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863650/psn-pdf
    February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback February 28, 2024 https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking- and-performance Summary To improve patient care and outcomes in the intensive care unit (ICU…
  10. psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
    November 26, 2014 - SPOTLIGHT CASE Transfusion Thresholds in Gastrointestinal Bleeding Citation Text: Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citati…
  11. psnet.ahrq.gov/web-mm/more-treatment-better-care
    August 11, 2021 - More Treatment—Better Care? Citation Text: Redberg R. More Treatment—Better Care?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49663/psn-pdf
    September 01, 2012 - Peripheral IV in Too Long September 1, 2012 Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long Case Objectives Appreciate the complications associated with peripheral intravenous (IV) catheters. Describe the optimal sterile technique that should be us…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49676/psn-pdf
    February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841139/psn-pdf
    December 14, 2022 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. December 14, 2022 Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. PSNet [internet]. 2022. https://psnet.ah…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49645/psn-pdf
    February 01, 2012 - E-prescribing: E for error? February 1, 2012 Ashton EW. E-prescribing: E for error? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/e-prescribing-e-error Case Objectives Define e-prescribing. Describe ways in which e-prescribing can reduce health care costs. State how commonly prescription errors occur wit…
  16. psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
    November 13, 2024 - The Second Victim Phenomenon: A Harsh Reality of Health Care Professions Susan D. Scott RN, MSN | May 1, 2011  View more articles from the same authors. Citation Text: Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [intern…
  17. psnet.ahrq.gov/print/pdf/node/867461
    January 31, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Patient and Family Engagement in Long Term Care Curated Library Foundations Long-term Care and Patient Safety Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA | April, 10 2024 A large and growing number of Americans require care in skilled nursin…
  18. psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
    January 29, 2021 - SPOTLIGHT CASE A Missed Bowel Perforation - the Importance of Diagnostic Reasoning Citation Text: Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
  19. psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
    September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety Robert M. Wachter, MD | September 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Wachter R. Playing Well with Others: "Translocational Research" in…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74226/psn-pdf
    February 01, 2019 - Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids January 7, 2022 https://psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-miti…

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