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2941. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49821/psn-pdf
      February 01, 2018 - Right Place, Right Drug, Wrong Strength February 1, 2018 Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength The Case A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…

2942. WebM&M: Case Studies | PSNet
      psnet.ahrq.gov/webmm-case-studies
      March 25, 2025 - WebM&M: Case Studies WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…

2943. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
      January 01, 2021 - Spotlight Spotlight An Inadvertent Bolus of Norepinephrine Source and Credits • This presentation is based on the May 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarina Fazio, PhD, RN, Emma Blackmon, PhD, RN, Amy Doroy, PhD,…

2944. SafeMedication.com. | PSNet
      psnet.ahrq.gov/issue/safemedicationcom
      July 10, 2019 - July 22, 2015 Nursing Home Compare.

2945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33722/psn-pdf
      December 01, 2011 - In Conversation With… Ann L. Hendrich, RN, PhD December 1, 2011 In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd Editor's note: Ann L. Hendrich, RN, PhD, is Vice President of Clinical Excellence Operations and Executive Di…

2946. Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study. | PSNet
      psnet.ahrq.gov/issue/correlation-between-number-patient-reported-adverse-events-adverse-drug-events-and-quality
      August 10, 2022 - August 19, 2020 Impact of a pharmacist-administered deprescribing intervention on nursing … home residents: a randomized controlled trial.

2947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49569/psn-pdf
      September 01, 2008 - In 1994, https://psnet.ahrq.gov/web-mm/wheres-feeding-tube the prevalence of tube feeding in nursing … home residents ranged from 7.5% in Maine to 40.1% in Mississippi.(1) Numerous types of tubes can be

2948. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. | PSNet
      psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
      October 31, 2023 - SPOTLIGHT CASE Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. Citation Text: Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…

2949. Chemotherapy Administration Safety Standards | PSNet
      psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
      March 30, 2016 - Chemotherapy Administration Safety Standards Citation Text: Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX En…

2950. Medication Handling and Compounding Errors in the Operating Room. | PSNet
      psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
      May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room. Citation Text: Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

2951. Attitudes to teamwork and safety in the operating theatre. | PSNet
      psnet.ahrq.gov/issue/attitudes-teamwork-and-safety-operating-theatre
      December 22, 2010 - Study Attitudes to teamwork and safety in the operating theatre. Citation Text: Flin R, Yule S, McKenzie L, et al. Attitudes to teamwork and safety in the operating theatre. Surgeon. 2006;4(3):145-51. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNo…

2952. The emotional fallout from the culture of blame and shame. | PSNet
      psnet.ahrq.gov/issue/emotional-fallout-culture-blame-and-shame
      October 28, 2020 - Commentary The emotional fallout from the culture of blame and shame. Citation Text: Ferguson CC. The emotional fallout from the culture of blame and shame. JAMA Pediatr. 2017;171(12):1141. doi:10.1001/jamapediatrics.2017.2691. Copy Citation Format: DOI Google Scholar PubMe…

2953. Safety for all: integrated design for inpatient units. | PSNet
      psnet.ahrq.gov/issue/safety-all-integrated-design-inpatient-units
      June 01, 2016 - Newspaper/Magazine Article Safety for all: integrated design for inpatient units. Citation Text: Safety for all: integrated design for inpatient units. Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28. Copy Citation Save Save to your library …

2954. Dramatic drop in cancer diagnoses amid COVID pandemic is cause for concern, doctors say. | PSNet
      psnet.ahrq.gov/issue/dramatic-drop-cancer-diagnoses-amid-covid-pandemic-cause-concern-doctors-say
      May 06, 2020 - August 26, 2020 Nursing home workers warned government about safety violations before

2955. Check Twice, Transport Once | PSNet
      psnet.ahrq.gov/web-mm/check-twice-transport-once
      March 15, 2023 - Check Twice, Transport Once Citation Text: DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

2956. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
      January 01, 2024 - Spotlight Spotlight A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis 1 Source and Credits This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Garth Utter, MD, MSc, FACS…

2957. Prevalence of medication administration errors in two medical units with automated prescription and dispensing. | PSNet
      psnet.ahrq.gov/issue/prevalence-medication-administration-errors-two-medical-units-automated-prescription-and
      February 26, 2020 - Study Prevalence of medication administration errors in two medical units with automated prescription and dispensing. Citation Text: Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. Prevalence of medication administration errors in two medical units with automated presc…

2958. Look alike/sound alike drugs: a literature review on causes and solutions. | PSNet
      psnet.ahrq.gov/issue/look-alikesound-alike-drugs-literature-review-causes-and-solutions
      September 28, 2022 - Review Look alike/sound alike drugs: a literature review on causes and solutions. Citation Text: Ciociano N, Bagnasco L. Look alike/sound alike drugs: a literature review on causes and solutions. Int J Clin Pharm. 2014;36(2):233-242. doi:10.1007/s11096-013-9885-6. Copy Citation For…

2959. Factors influencing providers' willingness to deprescribe medications. | PSNet
      psnet.ahrq.gov/issue/factors-influencing-providers-willingness-deprescribe-medications
      November 17, 2021 - Study Factors influencing providers' willingness to deprescribe medications. Citation Text: Davila H, Rosen AK, Stolzmann K, et al. Factors influencing providers' willingness to deprescribe medications. J Am Coll Clin Pharm. 2022;5:15-25. doi:10.1002/jac5.1537. Copy Citation Format…

2960. Validation of hospital administrative dataset for adverse event screening. | PSNet
      psnet.ahrq.gov/issue/validation-hospital-administrative-dataset-adverse-event-screening
      May 21, 2009 - Study Validation of hospital administrative dataset for adverse event screening. Citation Text: Verelst S, Jacques J, Van den Heede K, et al. Validation of Hospital Administrative Dataset for adverse event screening. Qual Saf Health Care. 2010;19(5):e25. doi:10.1136/qshc.2009.034306. …