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3381. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49543/psn-pdf
      September 01, 2007 - Medication Reconciliation: Whose Job Is It? September 1, 2007 Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it Case Objectives Appreciate the prevalence and impact of medication discrepancies at times of transition in …

3382. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73335/psn-pdf
      May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …

3383. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836978/psn-pdf
      May 16, 2022 - Check Twice, Transport Once May 16, 2022 DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/check-twice-transport-once The Case Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal pain and was diagnosed with “s…

3384. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49428/psn-pdf
      January 01, 2004 - To Resuscitate or Not? January 1, 2004 Wu AW, Pronovost P. To Resuscitate or Not? PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/resuscitate-or-not The Case A critically ill end-stage AIDS patient was hospitalized for end-of-life care. Given the state of his disease, his code status was Do Not Resuscitate/…

3385. Discharge Planning and Transitions of Care | PSNet
      psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
      June 15, 2024 - Discharge Planning and Transitions of Care Citation Text: Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibT…

3386. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49747/psn-pdf
      December 01, 2015 - Harm From Alarm Fatigue December 1, 2015 Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue Case Objectives Define alarm fatigue and describe potential errors that can occur due to alarm fatigue. Identify federal and national agencies focusing on …

3387. FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. | PSNet
      psnet.ahrq.gov/issue/fdas-promised-guidance-pulse-oximeters-unlikely-end-decades-racial-bias
      November 06, 2024 - Newspaper/Magazine Article FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. Citation Text: Allen A. FDA’s promised guidance on pulse oximeters unlikely to end decades of racial bias. KFF Health News. October 07, 2024; Copy Citation Format: …

3388. Mary Lanning Memorial Hospital: communication is key. | PSNet
      psnet.ahrq.gov/issue/mary-lanning-memorial-hospital-communication-key
      July 16, 2015 - Award Recipient Mary Lanning Memorial Hospital: communication is key. Citation Text: Lindblad B, Chilcott J, Rolls L. Mary Lanning Memorial Hospital: communication is key. Joint Commission journal on quality and safety. 2004;30(10):551-8. Copy Citation Format: Google Schola…

3389. Post-hospital medication discrepancies at home: risk factor for 90-day return to emergency department. | PSNet
      psnet.ahrq.gov/issue/post-hospital-medication-discrepancies-home-risk-factor-90-day-return-emergency-department
      March 18, 2020 - Study Post-hospital medication discrepancies at home: risk factor for 90-day return to emergency department. Citation Text: Costa LL, Byon HD. Post-Hospital Medication Discrepancies at Home: Risk Factor for 90-Day Return to Emergency Department. J Nurs Care Qual. 2018;33(2):180-186. doi:…

3390. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
      January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic January 12, 2022  Also Read the Conversation View more articles from the same authors. Citation Text: Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and…

3391. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation | PSNet
      psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
      June 28, 2023 - SPOTLIGHT CASE Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation Citation Text: Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. Rockville (MD): Agency for Healt…

3392. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838197/psn-pdf
      September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. September 28, 2022 Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022. https://psnet.…

3393. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49699/psn-pdf
      February 01, 2014 - Multifactorial Medication Mishap February 1, 2014 Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Id…

3394. Acute Respiratory Arrest in Pregnancy | PSNet
      psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
      August 15, 2018 - Acute Respiratory Arrest in Pregnancy Citation Text: Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

3395. Physician Burnout. | PSNet
      psnet.ahrq.gov/issue/physician-burnout
      May 01, 2017 - January 24, 2018 AHRQ Nursing Home Survey on Patient Safety Culture: 2016 User Comparative

3396. Pro/con debate: color-coded medication labels. | PSNet
      psnet.ahrq.gov/issue/procon-debate-color-coded-medication-labels
      December 23, 2008 - Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention in a nursing … home.

3397. Radiation Therapy Safety: The Critical Role of the Radiation Therapist. | PSNet
      psnet.ahrq.gov/issue/radiation-therapy-safety-critical-role-radiation-therapist
      June 20, 2014 - November 30, 2016 Nursing Home Survey on Patient Safety Culture: 2011 User Comparative

3398. Circle Up Training. | PSNet
      psnet.ahrq.gov/issue/circle-training
      February 22, 2023 - November 11, 2020 National Nursing Home COVID Action Network.

3399. AHRQ Safety Program for Methicillin-Resistant Staphylococcus Aureus Prevention. Request for Proposal Comment. | PSNet
      psnet.ahrq.gov/issue/ahrq-safety-program-methicillin-resistant-staphylococcus-aureus-prevention-request-proposal
      June 16, 2021 - June 16, 2021 Agency information collection activities: Nursing Home Survey on Patient

3400. Assessing the Evidence for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria. | PSNet
      psnet.ahrq.gov/issue/assessing-evidence-context-sensitive-effectiveness-and-safety-patient-safety-practices
      July 27, 2018 - January 10, 2024 Resident Safety Practices in Nursing Home Settings.