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  1. Communication Error in a Closed ICU | PSNet

    psnet.ahrq.gov/web-mm/communication-error-closed-icu
    July 01, 2016 - Communication Error in a Closed ICU Citation Text: Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49768/psn-pdf
    September 01, 2016 - Physician intervention for medication reduction in a nursing home: the polypharmacy outcomes project

  3. Unintended Consequences of CPOE | PSNet

    psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
    September 01, 2004 - SPOTLIGHT CASE Unintended Consequences of CPOE Citation Text: Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNot…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851568/psn-pdf
    July 31, 2023 - A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion July 31, 2023 Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomid…

  5. Translating From Normal to Abnormal | PSNet

    psnet.ahrq.gov/web-mm/translating-normal-abnormal
    October 02, 2019 - SPOTLIGHT CASE Translating From Normal to Abnormal Citation Text: Turner AM. Translating From Normal to Abnormal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…

  6. Don't Use That Port: Insert a PICC | PSNet

    psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
    December 22, 2018 - Don't Use That Port: Insert a PICC Citation Text: Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

  7. Glucose Roller Coaster | PSNet

    psnet.ahrq.gov/web-mm/glucose-roller-coaster
    February 02, 2022 - Glucose Roller Coaster Citation Text: Sharpe B. Glucose Roller Coaster. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33711/psn-pdf
    May 01, 2011 - The Second Victim Phenomenon: A Harsh Reality of Health Care Professions May 1, 2011 Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions Perspective The Instit…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49529/psn-pdf
    February 01, 2007 - Crossed Coverage February 1, 2007 Kayser SR. Crossed Coverage. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/crossed-coverage The Case A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation evaluation. She had already undergone multiple surgeries, including…

  10. Standard Deviations | PSNet

    psnet.ahrq.gov/web-mm/standard-deviations
    January 01, 2006 - SPOTLIGHT CASE Standard Deviations Citation Text: Sabin JE. Standard Deviations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865656/psn-pdf
    April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous Combination April 24, 2024 Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination The Case A 26-ye…

  12. Silent Pain in the Neck | PSNet

    psnet.ahrq.gov/web-mm/silent-pain-neck
    August 19, 2020 - Silent Pain in the Neck Citation Text: Bittner EA. Silent Pain in the Neck. 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 Endnote tagged Pu…

  13. Measurement of ambulatory medication errors in children: a scoping review. | PSNet

    psnet.ahrq.gov/issue/measurement-ambulatory-medication-errors-children-scoping-review
    February 07, 2024 - Review Measurement of ambulatory medication errors in children: a scoping review. Citation Text: Rickey L, Auger K, Britto MT, et al. Measurement of ambulatory medication errors in children: a scoping review. Pediatrics. 2023;152(6):e2023061281. doi:10.1542/peds.2023-061281. Copy Citat…

  14. Research in Ambulatory Patient Safety 2000-2010: A 10-Year Review. | PSNet

    psnet.ahrq.gov/issue/research-ambulatory-patient-safety-2000-2010-10-year-review
    March 11, 2015 - Book/Report Classic Research in Ambulatory Patient Safety 2000-2010: A 10-Year Review. Citation Text: Research in Ambulatory Patient Safety 2000-2010: A 10-Year Review. Lorincz CY, Drazen E, Sokol PE, et al. Chicago, IL: American Medical Association; 2011. Cop…

  15. The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. | PSNet

    psnet.ahrq.gov/issue/role-patient-involvement-diagnostic-process-internal-medicine-cognitive-approach
    April 25, 2012 - Commentary The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. Citation Text: Lucchiari C, Pravettoni G. The role of patient involvement in the diagnostic process in internal medicine: a cognitive approach. Eur J Intern Med. 2013;24(5):4…

  16. A safety maturity model for technology-induced errors. | PSNet

    psnet.ahrq.gov/issue/safety-maturity-model-technology-induced-errors
    June 15, 2022 - Review A safety maturity model for technology-induced errors. Citation Text: Borycki EM, Kushniruk AW. A safety maturity model for technology-induced errors. Stud Health Technol Inform. 2022;289:447-451. doi:10.3233/shti210954. Copy Citation Format: DOI Google Scholar BibTe…

  17. Perceived causes of prescribing errors by junior doctors in hospital inpatients: a study from the PROTECT programme. | PSNet

    psnet.ahrq.gov/issue/perceived-causes-prescribing-errors-junior-doctors-hospital-inpatients-study-protect
    April 19, 2011 - Study Perceived causes of prescribing errors by junior doctors in hospital inpatients: a study from the PROTECT programme. Citation Text: Ross S, Ryan C, Duncan EM, et al. Perceived causes of prescribing errors by junior doctors in hospital inpatients: a study from the PROTECT programm…

  18. Predictive combinations of monitor alarms preceding in-hospital code blue events. | PSNet

    psnet.ahrq.gov/issue/predictive-combinations-monitor-alarms-preceding-hospital-code-blue-events
    March 18, 2020 - Study Predictive combinations of monitor alarms preceding in-hospital code blue events. Citation Text: Hu X, Sapo M, Nenov V, et al. Predictive combinations of monitor alarms preceding in-hospital code blue events. J Biomed Inform. 2012;45(5):913-21. doi:10.1016/j.jbi.2012.03.001. Copy…

  19. Use of a surgical safety checklist to improve team communication. | PSNet

    psnet.ahrq.gov/issue/use-surgical-safety-checklist-improve-team-communication
    August 08, 2018 - Commentary Use of a surgical safety checklist to improve team communication. Citation Text: Cabral RA, Eggenberger T, Keller K, et al. Use of a surgical safety checklist to improve team communication. AORN J. 2016;104(3):206-216. doi:10.1016/j.aorn.2016.06.019. Copy Citation Format…

  20. Minimizing inappropriate medications in older populations: a ten-step conceptual framework. | PSNet

    psnet.ahrq.gov/issue/minimizing-inappropriate-medications-older-populations-ten-step-conceptual-framework
    June 23, 2021 - Commentary Minimizing inappropriate medications in older populations: a ten-step conceptual framework. Citation Text: Scott IA, Gray LC, Martin J, et al. Minimizing inappropriate medications in older populations: a 10-step conceptual framework. Am J Med. 2012;125(6):529-37.e4. doi:10.1…
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