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4601. Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial. | PSNet
      psnet.ahrq.gov/issue/interdisciplinary-collaboration-across-secondary-and-primary-care-improve-medication-safety
      December 21, 2022 - Study Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial. Citation Text: Johansen JS, Halvorsen KH, Svendsen K, et al. Interdisciplinary collaboration across secondary and prima…

4602. Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications. | PSNet
      psnet.ahrq.gov/issue/intended-and-unintended-effects-large-scale-adverse-event-disclosure-controlled-after
      August 18, 2021 - Study Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications. Citation Text: Wagner TH, Taylor T, Cowgill E, et al. Intended and unintended effects of large-scale adverse event disclosure: a controlled…

4603. Impact of inpatient harms on hospital finances and patient clinical outcomes. | PSNet
      psnet.ahrq.gov/issue/impact-inpatient-harms-hospital-finances-and-patient-clinical-outcomes
      February 28, 2018 - Study Classic Impact of inpatient harms on hospital finances and patient clinical outcomes. Citation Text: Adler L, Yi D, Li M, et al. Impact of Inpatient Harms on Hospital Finances and Patient Clinical Outcomes. J Patient Saf. 2018;14(2):67-73. doi:10.1097/PTS.…

4604. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866343/psn-pdf
      December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency December 31, 2024 Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…

4605. Lost in Transition | PSNet
      psnet.ahrq.gov/web-mm/lost-transition
      November 17, 2010 - SPOTLIGHT CASE Lost in Transition Citation Text: Beach C. Lost in Transition. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

4606. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49810/psn-pdf
      November 01, 2017 - Palliative Care: Comfort vs. Harm November 1, 2017 Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm Case Objectives Recognize errors may be difficult to identify in palliative care. State that medication errors and errors in communica…

4607. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49765/psn-pdf
      August 21, 2016 - Cognitive Overload in the ICU August 21, 2016 Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/cognitive-overload-icu Case Objectives Identify the role of cognitive overload—especially interruptions—in compromising quality of care and patient safety. List…

4608. Special Edition Perspective: Technology Responses to COVID-19 | PSNet
      psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19
      August 31, 2020 - Special Edition Perspective: Technology Responses to COVID-19 July 21, 2020  View more articles from the same authors. Citation Text: Marcin JP, Cohen NM, Lowery C, et al. Special Edition Perspective: Technology Responses to COVID-19. PSNet [internet]. Rockville (M…

4609. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49467/psn-pdf
      December 01, 2004 - A "Weak" Response December 1, 2004 Reisman AB. A "Weak" Response. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/weak-response The Case A primary care physician on call for his group received a call at 9:00PM from a 68-year-old man. He said, "They started me on a new pill for my blood pressure and now I fe…

4610. Patient Identification Errors: A Systems Challenge | PSNet
      psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
      February 23, 2011 - Patient Identification Errors: A Systems Challenge Citation Text: Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Googl…

4611. Bowel Injury After Laparoscopic Surgery | PSNet
      psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
      January 19, 2016 - Bowel Injury After Laparoscopic Surgery Citation Text: Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML …

4612. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules | PSNet
      psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
      March 25, 2020 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules Citation Text: Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…

4613. How Does Infection Prevention Fit Into a Safety Program? | PSNet
      psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
      March 01, 2014 - it serves as the vehicle through which approximately 12,000 US medical facilities (e.g., hospitals, nursing … homes, ambulatory surgical centers, hemodialysis units) report numerous HAIs.

4614. In Conversation With… Alison Holmes, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
      March 01, 2014 - it serves as the vehicle through which approximately 12,000 US medical facilities (e.g., hospitals, nursing … homes, ambulatory surgical centers, hemodialysis units) report numerous HAIs.

4615. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
      June 01, 2014 - PowerPoint Presentation Spotlight Wandering Off the Floors: Safety and Security Risks of Patient Wandering 1 This presentation is based on the June 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Thomas A. Smith, CHPA, CPP, President, Healthc…

4616. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33753/psn-pdf
      August 22, 2013 - Update on Safety Culture August 22, 2013 Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/update-safety-culture Perspective Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians treat each other with r…

4617. Introducing the Redesigned AHRQ Patient Safety Network | PSNet
      psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
      December 01, 2005 - Introducing the Redesigned AHRQ Patient Safety Network Robert M. Wachter, MD | November 1, 2015  View more articles from the same authors. Citation Text: Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. Rockville (MD): Agency f…

4618. Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective | PSNet
      psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
      June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective Zahra Khudeira, PharmD | June 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Khudeira Z. Becoming a Certified Professional in Patient Safet…

4619. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60721/psn-pdf
      July 21, 2020 - Special Edition Perspective: Technology Responses to COVID-19 July 21, 2020 Marcin JP, Cohen NM, Lowery C, et al. Special Edition Perspective: Technology Responses to COVID-19. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19 Editor’s note: This …

4620. Miscommunication During the Interhospital Transport of a Critically Ill Child | PSNet
      psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
      March 27, 2024 - Miscommunication During the Interhospital Transport of a Critically Ill Child Citation Text: Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human …