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3701. Medication errors in outpatient pediatrics. | PSNet
      psnet.ahrq.gov/issue/medication-errors-outpatient-pediatrics
      December 07, 2022 - Commentary Medication errors in outpatient pediatrics. Citation Text: Berrier K. Medication Errors in Outpatient Pediatrics. MCN Am J Matern Child Nurs. 2016;41(5):280-6. doi:10.1097/NMC.0000000000000261. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML…

3702. Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust. | PSNet
      psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-and-recommendations-independent-review-maternity-services
      April 27, 2022 - Book/Report Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust. Citation Text: Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at …

3703. CMS 30-minute rule for drug administration needs revision. | PSNet
      psnet.ahrq.gov/issue/cms-30-minute-rule-drug-administration-needs-revision
      October 21, 2021 - Newspaper/Magazine Article CMS 30-minute rule for drug administration needs revision. Citation Text: CMS 30-minute rule for drug administration needs revision. ISMP Medication Safety Alert! Acute Care Edition. September 9, 2010;15:1-6.  Copy Citation Save …

3704. Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside. | PSNet
      psnet.ahrq.gov/issue/oops-sorry-wrong-patient-patient-verification-process-needed-everywhere-not-just-bedside
      March 15, 2022 - Newspaper/Magazine Article Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside. Citation Text: Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside. ISMP Medication Safety Alert! Acut…

3705. ISMP Medication Safety Self Assessment for High-Alert Medications. | PSNet
      psnet.ahrq.gov/issue/ismp-medication-safety-self-assessment-high-alert-medications
      June 07, 2017 - Measurement Tool/Indicator ISMP Medication Safety Self Assessment for High-Alert Medications. Citation Text: ISMP Medication Safety Self Assessment for High-Alert Medications. Horsham, PA: Institute for Safe Medication Practices; 2017. Copy Citation Save Save to y…

3706. Implement strategies to prevent persistent medication errors and hazards: 2024. | PSNet
      psnet.ahrq.gov/issue/implement-strategies-prevent-persistent-medication-errors-and-hazards-2024
      April 17, 2024 - Newspaper/Magazine Article Implement strategies to prevent persistent medication errors and hazards: 2024. Citation Text: Implement strategies to prevent persistent medication errors and hazards: 2024. ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4. Copy Citation …

3707. 10 derm mistakes you don't want to make. | PSNet
      psnet.ahrq.gov/issue/10-derm-mistakes-you-dont-want-make
      March 26, 2008 - Commentary 10 derm mistakes you don't want to make. Citation Text: Fox GN. 10 derm mistakes you don't want to make. J Fam Pract. 2008;57(3):162-9. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downloa…

3708. Doctors were alarmed: would I have my children have surgery here? | PSNet
      psnet.ahrq.gov/issue/doctors-were-alarmed-would-i-have-my-children-have-surgery-here
      February 19, 2020 - Newspaper/Magazine Article Doctors were alarmed: would I have my children have surgery here? Citation Text: Doctors were alarmed: would I have my children have surgery here? Gabler E. New York Times. May 31, 2019. Copy Citation Save Save to your library Pr…

3709. Final Progress Report: Human Factors and Systems Integration in High Technology Surgery (HF-SIgHTS) (pdf file)
      www.ahrq.gov/sites/default/files/2025-07/catchpole-report.pdf
      January 01, 2025 - Thus, adverse outcomes can be seen both as the “unlucky” co-incidence of multiple randomly occurring

3710. Facilitator Guide: Overview of the Improvement Model (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_overview_impmodel_facnotes.docx
      December 01, 2017 - A premortem helps prevent losses from occurring. … Premortem Exercise SAY: In step three, think about what actions you can take to prevent that failure from occurring

3711. Program Overview: Facilitator Notes | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/tools/surgery/modules/on-boarding/overview-fac-notes.html
      December 01, 2017 - A premortem helps prevent losses from occurring. … Exercise Say: In step three, think about what actions you can take to prevent that failure from occurring

3712. The Role of Graduate Medical Education (GME) in Improving Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
      February 01, 2010 - Similar sorts of innovations are occurring in many other academic institutions nationally. … Handoffs are occurring at multiple levels in the system at the same time.

3713. In Conversation with…Thomas J. Nasca, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
      February 01, 2010 - Handoffs are occurring at multiple levels in the system at the same time. … Similar sorts of innovations are occurring in many other academic institutions nationally.

3714. Final Progress Report: Risks of Inaccurate or Incomplete Preoperative Assessments in Freestanding ASCs (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/kupka-report.pdf
      January 01, 2024 - Final Progress Report: Risks of Inaccurate or Incomplete Preoperative Assessments in Freestanding ASCs Title Page Title of Project: Risks Of Inaccurate Or Incomplete Preoperative Assessments In Freestanding ASCs Principal Investigator: Nancy Kupka DNSc, MPH, RN - The Joint Commission Team Members: Diana Bickham, …

3715. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/849679/psn-pdf
      June 28, 2023 - by or on patients” and relevant financial relationships as “financial relationships in any amount occurring

3716. Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
      January 01, 2023 - Significance (2) • Hospital admission increases the risk for VTE in pregnancy 17-fold with the greatest risk occurring

3717. Patient Safety Events Involving Opioid Dose Stacking | PSNet
      psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
      July 08, 2022 - or used on patients” and relevant financial relationships as “financial relationships in any amount occurring

3718. Spotlight Case September 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
      September 01, 2003 - Spotlight Case September 2003 Spotlight Case September 2003 Infant Paralyzed for Intubation Before Airway Materials Ready Source and Credits This presentation is based on the Sept. 2003 AHRQ WebM&M Spotlight Case in Pediatrics See the full article at http://webmm.ahrq.gov CME credit is available through the …

3719. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49559/psn-pdf
      April 01, 2008 - The Forgotten Drip April 1, 2008 Josephson AS. The Forgotten Drip. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/forgotten-drip The Case A 45-year-old man was brought to the emergency department by his friends because of a 1-day history of a severe headache and "bizarre behavior." A computed tomography (C…

3720. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33755/psn-pdf
      September 01, 2013 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety September 1, 2013 Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/what-weve-learned-ab…