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  1. Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy. | PSNet

    psnet.ahrq.gov/issue/description-role-pharmacist-independent-double-checks-during-cognitive-order-verification
    March 10, 2021 - Study Description of the role of pharmacist independent double checks during cognitive order verification of outpatient parenteral anti-cancer therapy. Citation Text: Booth JP, Kennerly-Shah JM, Hartman AD. Description of the role of pharmacist independent double checks during cognitive …

  2. COVID-19: patient safety and quality improvement skills to deploy during the surge. | PSNet

    psnet.ahrq.gov/issue/covid-19-patient-safety-and-quality-improvement-skills-deploy-during-surge
    March 23, 2022 - Commentary COVID-19: patient safety and quality improvement skills to deploy during the surge. Citation Text: Staines A, Amalberti R, Berwick DM, et al. COVID-19: patient safety and quality improvement skills to deploy during the surge. Int J Qual Health Care. 2021;33(1):mzaa050. doi:10.…

  3. Making safety training stickier: a richer model of safety training engagement and transfer. | PSNet

    psnet.ahrq.gov/issue/making-safety-training-stickier-richer-model-safety-training-engagement-and-transfer
    October 06, 2021 - Review Making safety training stickier: a richer model of safety training engagement and transfer. Citation Text: Casey T, Turner N, Hu X, et al. Making safety training stickier: a richer model of safety training engagement and transfer. J Safety Res. 2021;78:303-313. doi:10.1016/j.jsr.2…

  4. Is there a mismatch between the perspectives of patients and regulators on healthcare quality? A survey study. | PSNet

    psnet.ahrq.gov/issue/there-mismatch-between-perspectives-patients-and-regulators-healthcare-quality-survey-study
    September 08, 2021 - Study Is there a mismatch between the perspectives of patients and regulators on healthcare quality? A survey study. Citation Text: Bouwman R, Bomhoff M, Robben PB, et al. Is there a mismatch between the perspectives of patients and regulators on healthcare quality? A survey study. J Pat…

  5. An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management. | PSNet

    psnet.ahrq.gov/issue/evidence-and-consensus-based-definition-second-victim-strategic-topic-healthcare-quality
    September 13, 2023 - Commentary An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management. Citation Text: Vanhaecht K, Seys D, Russotto S, et al. An evidence and consensus-based definition of second …

  6. Errors in palliative care: kinds, causes, and consequences: a pilot survey of experiences and attitudes of palliative care professionals. | PSNet

    psnet.ahrq.gov/issue/errors-palliative-care-kinds-causes-and-consequences-pilot-survey-experiences-and-attitudes
    December 04, 2016 - Study Errors in palliative care: kinds, causes, and consequences: a pilot survey of experiences and attitudes of palliative care professionals. Citation Text: Dietz I, Borasio GD, Molnar C, et al. Errors in palliative care: kinds, causes, and consequences: a pilot survey of experiences a…

  7. Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: a survey study. | PSNet

    psnet.ahrq.gov/issue/changes-primary-care-delivery-during-covid-19-pandemic-and-perceived-impact-medication-safety
    January 18, 2023 - Study Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: a survey study. Citation Text: Gleeson LL, Ludlow A, Wallace E, et al. Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: a…

  8. Time to listen: a review of methods to solicit patient reports of adverse events. | PSNet

    psnet.ahrq.gov/issue/time-listen-review-methods-solicit-patient-reports-adverse-events
    November 23, 2016 - Review Time to listen: a review of methods to solicit patient reports of adverse events. Citation Text: King A, Daniels J, Lim J, et al. Time to listen: a review of methods to solicit patient reports of adverse events. Qual Saf Health Care. 2010;19(2):148-57. doi:10.1136/qshc.2008.0301…

  9. Intervention study for the reduction of medication errors in elderly trauma patients. | PSNet

    psnet.ahrq.gov/issue/intervention-study-reduction-medication-errors-elderly-trauma-patients
    December 18, 2019 - Study Intervention study for the reduction of medication errors in elderly trauma patients. Citation Text: Parro Martín M de los Á, Muñoz García M, Delgado Silveira E, et al. Intervention study for the reduction of medication errors in elderly trauma patients. J Eval Clin Pract. 2021;27(…

  10. Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. | PSNet

    psnet.ahrq.gov/issue/error-reduction-pediatric-chemotherapy-computerized-order-entry-and-failure-modes-and-effects
    August 02, 2010 - Study Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Citation Text: Kim G, Chen AR, Arceci RJ, et al. Error reduction in pediatric chemotherapy: computerized order entry and failure modes and effects analysis. Arch Pediatr Ad…

  11. Assessment of patient retention of inpatient care information post-hospitalization. | PSNet

    psnet.ahrq.gov/issue/assessment-patient-retention-inpatient-care-information-post-hospitalization
    June 01, 2022 - Study Assessment of patient retention of inpatient care information post-hospitalization. Citation Text: Townshend R, Grondin C, Gupta A, et al. Assessment of patient retention of inpatient care information post-hospitalization. Jt Comm J Qual Patient Saf. 2023;49(2):70-78. doi:10.1016/j…

  12. Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up | PSNet

    psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
    September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up Citation Text: Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…

  13. In Conversation With… Jeffrey Starke, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-jeffrey-starke-md
    September 11, 2023 - In Conversation With… Jeffrey Starke, MD October 1, 2017  Citation Text: In Conversation With… Jeffrey Starke, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Form…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49862/psn-pdf
    May 01, 2019 - The Magnetic Deflection May 1, 2019 Kanal E. The Magnetic Deflection. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/magnetic-deflection The Case A 68-year-old woman with a prior history of cerebrovascular accident and hypertension presented to the hospital with new left-sided weakness and hypertensive urg…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49488/psn-pdf
    August 21, 2005 - PCA Overdose August 21, 2005 Doyle JD. PCA Overdose. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pca-overdose The Case A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo- oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49842/psn-pdf
    September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…

  17. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
    February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49477/psn-pdf
    April 01, 2005 - Hold the tPA April 1, 2005 Fagan SC. Hold the tPA. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hold-tpa The Case A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…

  19. Bar Code Label Requirements for Blood and Blood Components. | PSNet

    psnet.ahrq.gov/issue/bar-code-label-requirements-blood-and-blood-components
    May 04, 2015 - Fact Sheet/FAQs Bar Code Label Requirements for Blood and Blood Components. Citation Text: Bar Code Label Requirements for Blood and Blood Components. FDA; Food and Drug Administration; CBER; Center for Biologics Evaluation and Research. Copy Citation Save Sav…

  20. A surgeon so bad it was criminal. | PSNet

    psnet.ahrq.gov/issue/surgeon-so-bad-it-was-criminal
    October 24, 2018 - Newspaper/Magazine Article A surgeon so bad it was criminal. Citation Text: A surgeon so bad it was criminal. Beil L. ProPublica. October 2, 2018. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter L…
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