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3001. Situational (Un)Awareness | PSNet
      psnet.ahrq.gov/web-mm/situational-unawareness
      August 01, 2009 - Situational (Un)Awareness Citation Text: Abramson EL, Kaushal R. Situational (Un)Awareness. 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 E…

3002. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867428/psn-pdf
      December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-patricia-dykes-a…

3003. Near Miss with Bedside Medications | PSNet
      psnet.ahrq.gov/web-mm/near-miss-bedside-medications
      February 01, 2006 - SPOTLIGHT CASE Near Miss with Bedside Medications Citation Text: Wu AW. Near Miss with Bedside Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX End…

3004. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable | PSNet
      psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
      December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable Citation Text: Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…

3005. Missing ECG and Missed Diagnosis Lead to Dangerous Delay | PSNet
      psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
      March 01, 2015 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay Citation Text: O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: G…

3006. Measuring harm in health care: optimizing adverse event review. | PSNet
      psnet.ahrq.gov/issue/measuring-harm-health-care-optimizing-adverse-event-review
      May 15, 2013 - Study Measuring harm in health care: optimizing adverse event review. Citation Text: Walsh KE, Harik P, Mazor KM, et al. Measuring Harm in Health Care: Optimizing Adverse Event Review. Med Care. 2017;55(4):436-441. doi:10.1097/MLR.0000000000000679. Copy Citation Format: DOI…

3007. A scoping review of communication tools applicable to patients and their primary care providers after discharge from hospital. | PSNet
      psnet.ahrq.gov/issue/scoping-review-communication-tools-applicable-patients-and-their-primary-care-providers-after
      December 15, 2021 - Review A scoping review of communication tools applicable to patients and their primary care providers after discharge from hospital. Citation Text: Spencer RA, Singh Punia H. A scoping review of communication tools applicable to patients and their primary care providers after discharge …

3008. How useful are medication patient information leaflets to older adults? A content, readability and layout analysis. | PSNet
      psnet.ahrq.gov/issue/how-useful-are-medication-patient-information-leaflets-older-adults-content-readability-and
      November 11, 2020 - Study How useful are medication patient information leaflets to older adults? A content, readability and layout analysis. Citation Text: Liu F, Abdul-Hussain S, Mahboob S, et al. How useful are medication patient information leaflets to older adults? A content, readability and layout ana…

3009. Predicting potential postdischarge adverse drug events and 30-day unplanned hospital readmissions from medication regimen complexity. | PSNet
      psnet.ahrq.gov/issue/predicting-potential-postdischarge-adverse-drug-events-and-30-day-unplanned-hospital
      December 09, 2009 - Study Predicting potential postdischarge adverse drug events and 30-day unplanned hospital readmissions from medication regimen complexity. Citation Text: Schoonover H, Corbett CF, Weeks DL, et al. Predicting potential postdischarge adverse drug events and 30-day unplanned hospital readm…

3010. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49710/psn-pdf
      May 01, 2014 - Discontinued Medications: Are They Really Discontinued? May 1, 2014 Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued The Case A 69-year-old man with a history of chronic atrial f…

3011. Advancing Health Care Safety for All. | PSNet
      psnet.ahrq.gov/issue/advancing-health-care-safety-all
      July 19, 2024 - October 30, 2023 Agency information collection activities: Nursing Home Survey on Patient

3012. AHRQ Quality Indicators. | PSNet
      psnet.ahrq.gov/issue/ahrq-quality-indicators
      December 24, 2008 - August 12, 2016 Nursing Home Compare.

3013. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49430/psn-pdf
      January 01, 2004 - Triage Time Bomb January 1, 2004 Washington DL. Triage Time Bomb. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/triage-time-bomb The Case A parent presented with a child to the emergency department (ED) triage area (located around the corner and down the hall from the actual ED). The child was febrile, an…

3014. Reduction in chemotherapy order errors with computerised physician order entry and clinical decision support systems. | PSNet
      psnet.ahrq.gov/issue/reduction-chemotherapy-order-errors-computerised-physician-order-entry-and-clinical-decision
      October 22, 2014 - March 9, 2016 AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative

3015. Applying human-centered design thinking to enhance safety in the OR. | PSNet
      psnet.ahrq.gov/issue/applying-human-centered-design-thinking-enhance-safety-or
      May 25, 2016 - February 2, 2022 Systemic failures in nursing home care--a scoping study.

3016. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet
      psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
      November 27, 2019 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities Citation Text: Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…

3017. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36673/psn-pdf
      January 18, 2011 - Patient safety: honoring advanced directives. January 18, 2011 Tice MA. Patient safety: honoring advanced directives. Home Healthc Nurse. 2007;25(2):79-81. https://psnet.ahrq.gov/issue/patient-safety-honoring-advanced-directives The author discusses why failure to follow an advance directive should be considered a …

3018. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49544/psn-pdf
      September 01, 2007 - Discharging Our Responsibility September 1, 2007 Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/discharging-our-responsibility The Case A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure (CHF) presented to the …

3019. Unverified patient-reported error: a false alarm can have real consequences. | PSNet
      psnet.ahrq.gov/issue/unverified-patient-reported-error-false-alarm-can-have-real-consequences
      June 05, 2018 - Newspaper/Magazine Article Unverified patient-reported error: a false alarm can have real consequences. Citation Text: Unverified patient-reported error: a false alarm can have real consequences. ISMP Medication Safety Alert! Acute care edition. November 20, 2014;19:1-3. Copy Citation …

3020. Global Patient Safety Collaborative. | PSNet
      psnet.ahrq.gov/issue/who-collaborating-centres-patient-safety
      April 06, 2016 - May 5, 2021 National Nursing Home COVID Action Network.