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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - One month after placement, he received follow-up from a cardiologist and was informed he should remain
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psnet.ahrq.gov/issue/tenfold-therapeutic-dosing-errors-young-children-reported-us-poison-control-centers
July 10, 2024 - Study
Tenfold therapeutic dosing errors in young children reported to US poison control centers.
Citation Text:
Crouch BI, Caravati M, Moltz E. Tenfold therapeutic dosing errors in young children reported to U.S. poison control centers. Am J Health Syst Pharm. 2009;66(14):1292-6. doi:10…
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psnet.ahrq.gov/issue/ed-revamp-team-approach-care-reduces-errors-boosts-patient-and-clinician-satisfaction
June 14, 2023 - Newspaper/Magazine Article
ED revamp: team approach to care reduces errors, boosts patient and clinician satisfaction.
Citation Text:
ED revamp: team approach to care reduces errors, boosts patient and clinician satisfaction. ED management : the monthly update on emergency department m…
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psnet.ahrq.gov/innovation/pharmacist-led-mobile-health-intervention-and-transplant-medication-safety-randomized
April 07, 2021 - During the 12-month study period, findings show that the TRANSAFE Rx intervention significantly reduced
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psnet.ahrq.gov/node/866561/psn-pdf
August 21, 2024 - Medical malpractice litigation and daylight saving time.
August 21, 2024
Gao C, Lage C, Scullin MK. Medical malpractice litigation and daylight saving time. J Clin Sleep Med.
2024;20(6):933-940. doi:10.5664/jcsm.11038.
https://psnet.ahrq.gov/issue/medical-malpractice-litigation-and-daylight-saving-time
Sleep depri…
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psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
March 12, 2021 - The Case A 19-month-old boy was found unresponsive and not breathing by a parent; 911 was called and … Preparation Reference (Improved) The Commentary By Paul MacDowell, PharmD, BCPS, and Eloh McGee, PharmD A 19-month-old
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psnet.ahrq.gov/node/862613/psn-pdf
February 14, 2024 - Standardizing medication reconciliation in a pediatric
emergency department.
February 14, 2024
Sheth S, Bialostozky M, Hollenbach K, et al. Standardizing medication reconciliation in a pediatric
emergency department. Pediatrics. 2024;153(2):e2023061964. doi:10.1542/peds.2023-061964.
https://psnet.ahrq.gov/issue/st…
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psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
February 26, 2025 - Results
In the last 12 months of a 28-month study following implementation, the median monthly mortality … The number of patients diagnosed with sepsis did not change during the 28-month study.
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psnet.ahrq.gov/node/866434/psn-pdf
August 07, 2024 - Measuring the overall development of patient safety in a
new hospital using trigger tools.
August 7, 2024
Adamovic I, Dahlem P, Brachmann J. Measuring the overall development of patient safety in a new
hospital using trigger tools. Int J Qual Health Care. 2024;36(3):mzae064. doi:10.1093/intqhc/mzae064.
https://psn…
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - This article describes the efforts of 11 healthcare organizations' implementation and six-month sustainment … This article describes the efforts of 11 healthcare organizations' implementation and six-month sustainment
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psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-months-shutdown-then
July 18, 2018 - Newspaper/Magazine Article
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go.
Citation Text:
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. Massey W, Keith …
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psnet.ahrq.gov/node/49761/psn-pdf
May 01, 2016 - The patient saw his new PCP about 1 month later and reported fatigue, a chronic nonproductive cough, … He
scheduled the patient for a follow-up visit in 1 month.
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - The resident was in his final month of training, and would leave the
institution for fellowship at the … This process facilitated nearly 90% of acute patients being
seen in the first month.(16)
II.
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psnet.ahrq.gov/issue/any-new-process-poses-risk-errors-learning-4-months-coronavirus-disease-2019-covid-19
June 10, 2018 - Newspaper/Magazine Article
Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations.
Citation Text:
Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations. ISMP Medicat…
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psnet.ahrq.gov/issue/covid-19-can-last-several-months-diseases-long-haulers-have-endured-relentless-waves
April 03, 2005 - Newspaper/Magazine Article
COVID-19 can last for several months. The disease’s “long-haulers” have endured relentless waves of debilitating symptoms—and disbelief from doctors and friends.
Citation Text:
Young E. COVID-19 can last for several months. The disease’s “long-haulers” have end…
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psnet.ahrq.gov/node/846769/psn-pdf
March 29, 2023 - Missed Diagnosis of Addison’s Disease in Adolescent
Presenting with Fatigue.
March 29, 2023
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
The C…
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psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
June 01, 2015 - If the daily dose were to be continued for more than a month, this postmenopausal woman would be at a … Use of intraarticular glucocorticoids at 2- to 3-month intervals (i.e., to relieve a single painful, … Use of oral glucocorticoids in protocols in which they are tapered to zero dose within a month (i.e.,
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psnet.ahrq.gov/issue/first-do-no-harm
March 21, 2011 - Newspaper/Magazine Article
First do no harm.
Citation Text:
First do no harm. Allen M. Washington Monthly. March/April 2011.
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psnet.ahrq.gov/issue/falls-english-and-welsh-hospitals-national-observational-study-based-retrospective-analysis
June 15, 2011 - Study
Falls in English and Welsh hospitals: a national observational study based on retrospective analysis of 12 months of patient safety incident reports.
Citation Text:
Healey F, Scobie S, Oliver D, et al. Falls in English and Welsh hospitals: a national observational study based o…
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psnet.ahrq.gov/issue/opioid-prescribing-and-potential-overdose-errors-among-children-0-36-months-old
March 23, 2016 - Study
Opioid prescribing and potential overdose errors among children 0 to 36 months old.
Citation Text:
Basco WT, Ebeling M, Garner SS, et al. Opioid Prescribing and Potential Overdose Errors Among Children 0 to 36 Months Old. Clin Pediatr (Phila). 2015;54(8):738-44. doi:10.1177/0009922…