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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - Falling Between the Cracks in the Software
August 21, 2016
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-between-cracks-software
The Case
A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…
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psnet.ahrq.gov/node/49871/psn-pdf
August 10, 2019 - In addition to the errors of communication and education already mentioned, the patient's concerns about
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psnet.ahrq.gov/node/50928/psn-pdf
February 21, 2020 - standardization of workflow and creative solutions to countering patient safety
events such as those mentioned
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - setting is not contraindicated, but concomitant use does require strict adherence to the guidelines mentioned
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - checkpoint regarding medication ("Have all instruments and controlled drugs been accounted for") is first mentioned
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psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - standardization of workflow and creative solutions to countering patient safety events such as those mentioned
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - sound-alike medication and to include the change in naming convention as well as the order instructions mentioned
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psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
March 01, 2005 - SPOTLIGHT CASE
CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure
Citation Text:
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - For opioids, as I mentioned, some states have a mandate that dentists and other clinicians consult the
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psnet.ahrq.gov/web-mm/suicidal-man-gun
May 01, 2005 - Voluntary hospitalization, partly aimed at separating the patient from his gun, is not mentioned in the
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psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - This particular patient differed from those enrolled in the studies mentioned above in that she did not
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psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
November 01, 2012 - practice activities because of the fear of being sued.( 14 )
Considering the case presented and the data mentioned
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psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - Many of the educational programs and training sessions
mentioned above are designed to improve understanding
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psnet.ahrq.gov/node/49545/psn-pdf
September 01, 2007 - 0.08%.(3) The risk of death varies with age, as well as with the presence of the clinical
predictors mentioned
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psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - The barriers mentioned above are very real and impact our ability to learn from our mistakes.
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psnet.ahrq.gov/node/33614/psn-pdf
June 01, 2005 - For instance,
in the previously mentioned study of medication reconciliation (11), the outcome was "
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psnet.ahrq.gov/node/33762/psn-pdf
March 01, 2014 - You mentioned one, the delayed antibiotic idea. What are some of the others that
are taking root?
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - Anticoagulants, including warfarin (Coumadin), heparin, enoxaparin (Lovenox), and dalteparin (Fragmin), were mentioned
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psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
May 14, 2020 - JW : Neal had mentioned that there are these pockets of interested parties that they were working with … your schedule frequently, I would make sure the technology works, I would create a workflow like Neal mentioned
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psnet.ahrq.gov/perspective/conversation-james-augustine-md
July 28, 2021 - KH: Can we go back to the regional and state-level reporting programs you mentioned? … Role of Education
As previously mentioned, EMS personnel have different levels of licensure which