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psnet.ahrq.gov/node/50750/psn-pdf
January 01, 2020 - Patterns in medication incidents: a 10-yr experience of a
cross-national anaesthesia incident reporting system.
December 18, 2019
Sanduende-Otero Y, Villalón-Coca J, Romero-García E, et al. Patterns in medication incidents: A 10-yr
experience of a cross-national anaesthesia incident reporting system. Br J Anaesth. …
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psnet.ahrq.gov/node/60030/psn-pdf
March 11, 2020 - Soft factors, smooth transport? The role of safety climate
and team processes in reducing adverse events during
intrahospital transport in intensive care.
March 11, 2020
Latzke M, Schiffinger M, Zellhofer D, et al. Soft Factors, Smooth Transport? The role of safety climate and
team processes in reducing adverse ev…
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psnet.ahrq.gov/node/850933/psn-pdf
June 21, 2023 - The prevalence of second victim syndrome and emotional
distress in pediatric intensive care providers.
June 21, 2023
Wolf MS, Smith K, Basu M, et al. The prevalence of second victim syndrome and emotional distress in
pediatric intensive care providers. J Pediatr Intensive Care. 2023;12(02):125-130. doi:10.1055/s-00…
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psnet.ahrq.gov/node/74134/psn-pdf
December 01, 2021 - Remember that patient you saw last week: characteristics
and frequency of patients experiencing anticipated and
unanticipated death following ED discharge.
December 1, 2021
Hoang R, Sampsel K, Willmore A, et al. Remember that patient you saw last week: characteristics and
frequency of patients experiencing anticip…
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psnet.ahrq.gov/node/49615/psn-pdf
December 01, 2010 - ulcers, when they should also be used for high-risk
individuals on the "'front end"—before an ulcer occurs
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psnet.ahrq.gov/node/49393/psn-pdf
April 01, 2003 - Which End Is Which?
April 1, 2003
Campbell AR. Which End Is Which? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/which-end-which
The Case
A 39-year-old woman with chronic peri-anal fistulas and infected anal sinuses underwent laparoscopic
diverting colostomy to divert her fecal stream and allow the perine…
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psnet.ahrq.gov/node/49845/psn-pdf
October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug
Shortages
October 1, 2018
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
The Case
A 1-month-old preterm infant in the ne…
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psnet.ahrq.gov/issue/heed-warning-dont-miss-important-computer-alerts
May 07, 2018 - Newspaper/Magazine Article
Heed this warning! Don't miss important computer alerts.
Citation Text:
Heed this warning! Don't miss important computer alerts. ISMP Medication Safety Alert! Acute Care Edition. February 8, 2007;12:1-2.
Copy Citation
Save
Save to your l…
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psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - intimal tear originating within 2 cm of the aortic valve in 75% of cases.(
7) The aortic tear commonly occurs
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psnet.ahrq.gov/node/47502/psn-pdf
June 02, 2019 - Failure to debrief after critical events in anesthesia is
associated with failures in communication during the
event.
June 2, 2019
Arriaga AF, Sweeney RE, Clapp JT, et al. Failure to Debrief after Critical Events in Anesthesia Is
Associated with Failures in Communication during the Event. Anesthesiology. 2019;130(…
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psnet.ahrq.gov/node/49714/psn-pdf
August 21, 2014 - Microbial invasion of the subcutaneous tissues occurs either through external trauma (often seen in … The local pain is replaced by numbness, which occurs from
compression or infarction of the nerves.
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - individuals to make mistakes and (ii) to permit the detection and correction of errors before harm occurs … • Prevent malfunctioning or unintentional operation by reverting back to a safe state if failure occurs
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - When this occurs, implementing corrective action is very
difficult and time consuming and must follow … I fully realize that the kind of rude behavior displayed by the resident in this case still occurs
sometimes—even
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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Heparin-induced thrombocytopenia (HIT) occurs when heparin molecules stimulate formation of a
pathogenic … following use of
intravenous heparin.(11)
In contrast, coumarin-induced skin necrosis (CISN) rarely occurs
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psnet.ahrq.gov/node/33777/psn-pdf
January 01, 2015 - and teaches others, rather than creating a
separate, centralized structure where innovative thinking occurs
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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - How can we harness the surprise that occurs when a
provider or leader takes on a human factors engineering
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psnet.ahrq.gov/node/40745/psn-pdf
September 07, 2011 - A prospective observational study of physician handoff
for intensive-care-unit-to-ward patient transfers.
September 7, 2011
Li P, Stelfox HT, Ghali WA. A Prospective Observational Study of Physician Handoff for Intensive-Care-
Unit-to-Ward Patient Transfers. Am J Med. 2011;124(9). doi:10.1016/j.amjmed.2011.04.027.
…
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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psnet.ahrq.gov/node/73109/psn-pdf
April 07, 2021 - Common general surgical never events: analysis of NHS
England never event data.
April 7, 2021
Omar I, Singhal R, Wilson M, et al. Common general surgical never events: analysis of NHS England never
event data. Int J Qual Health Care. 2021;33(1):mzab045. doi:10.1093/intqhc/mzab045.
https://psnet.ahrq.gov/issue/comm…
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psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - Succinylcholine Trimethoprim Amiloride-like effect on distal tubule; occurs