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psnet.ahrq.gov/issue/safety-relevant-mode-confusions-modelling-and-reducing-them
April 28, 2021 - Commentary
Safety-relevant mode confusions—modelling and reducing them.
Citation Text:
Bredereke J, Lankenau A. Safety-relevant mode confusions—modelling and reducing them. Reliab Eng Syst Saf. 2004;88(3). doi:10.1016/j.ress.2004.07.020.
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psnet.ahrq.gov/issue/parents-perceptions-pediatric-day-surgery-risks-unforeseeable-complications-or-avoidable
September 11, 2019 - Study
Parents' perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes?
Citation Text:
Sobo EJ. Parents' perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes? Soc Sci Med. 2005;60(10):2341-50.
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psnet.ahrq.gov/issue/use-computers-clinical-care-case-series-advanced-us-sites
August 04, 2021 - Study
The use of computers for clinical care: a case series of advanced US sites.
Citation Text:
Doolan DF, Bates DW, James BC. The use of computers for clinical care: a case series of advanced U.S. sites. J Am Med Inform Assoc. 2003;10(1):94-107.
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psnet.ahrq.gov/issue/organizational-learning-and-patient-safety-hospital-pharmacy-settings
September 23, 2020 - Study
Organizational learning and patient safety: hospital pharmacy settings.
Citation Text:
Abdallah W, Johnson C, Nitzl C, et al. Organizational learning and patient safety: hospital pharmacy settings. J Health Organ Manag. 2019;33(6):695-713. doi:10.1108/JHOM-11-2018-0319.
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psnet.ahrq.gov/node/33864/psn-pdf
January 01, 2019 - How Does Health Care Simulation Affect Patient Care?
August 1, 2018
Lopreiato JO. How Does Health Care Simulation Affect Patient Care? PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
Perspective
Introduction
Health care simulation programs have spread…
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psnet.ahrq.gov/issue/safety-information-alaris-se-infusion-pumps
June 07, 2006 - Audiovisual
Safety Information on Alaris SE Infusion Pumps.
Citation Text:
Food and Drug Administration. 2006.
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November 15, 2…
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psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
January 07, 2015 - Dropping the Ball Despite an Integrated EMR
Citation Text:
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/49794/psn-pdf
May 01, 2017 - Communication Error in a Closed ICU
May 1, 2017
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/communication-error-closed-icu
The Case
A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney
transplant), co…
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psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - Hyperglycemia and Switching to Subcutaneous Insulin
December 1, 2015
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
The Case
A 47-year-old man with type 2 diabetes was admitted to the hospita…
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psnet.ahrq.gov/Webmm
May 01, 2021 - Spotlight Cases include interactive learning modules available for CME.
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psnet.ahrq.gov/webmm
May 01, 2021 - Spotlight Cases include interactive learning modules available for CME.
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psnet.ahrq.gov/node/60363/psn-pdf
March 01, 2021 - Training is supplemented by use of a Web-based modules.
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psnet.ahrq.gov/periodic-issue/periodic-issue-337
April 27, 2022 - April 13, 2022 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - Hyperglycemia and Switching to Subcutaneous Insulin
Citation Text:
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. 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/node/49865/psn-pdf
June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy
June 1, 2019
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
The Case
A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
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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…
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psnet.ahrq.gov/node/72563/psn-pdf
December 07, 2020 - In Conversation With... Katie J. Suda, PharmD, MS
December 7, 2020
In Conversation With.. Katie J. Suda, PharmD, MS . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
Editor’s Note: Katie J. Suda, PharmD, MS is a professor at the University of Pittsburgh School of Medic…
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psnet.ahrq.gov/issue/use-cellular-telephones-hospital-environment
November 26, 2014 - Study
Use of cellular telephones in the hospital environment.
Citation Text:
Tri JL, Severson RP, Hyberger LK, et al. Use of cellular telephones in the hospital environment. Mayo Clin Proc. 2007;82(3):282-5.
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psnet.ahrq.gov/perspective/communication-during-transitions-care
July 10, 2024 - Annual Perspective
Communication During Transitions of Care
Ayse P. Gurses; Sarah Mossburg; Zoe Sousane
| March 27, 2024
View more articles from the same authors.
Citation Text:
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…