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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - Medication Overdose
Citation Text:
Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - 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/38758/psn-pdf
July 08, 2009 - An international review of patient safety measures in
radiotherapy practice.
July 8, 2009
Shafiq J, Barton M, Noble DJ, et al. An international review of patient safety measures in radiotherapy
practice. Radiother Oncol. 2009;92(1):15-21. doi:10.1016/j.radonc.2009.03.007.
https://psnet.ahrq.gov/issue/international…
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psnet.ahrq.gov/node/44767/psn-pdf
January 20, 2016 - "What's psychology got to do with it?" Applying
psychological theory to understanding failures in modern
healthcare settings.
January 20, 2016
Rydon-Grange M. 'What's Psychology got to do with it?' Applying psychological theory to understanding
failures in modern healthcare settings. J Med Ethics. 2015;41(11):880-…
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psnet.ahrq.gov/node/40921/psn-pdf
November 16, 2011 - Adverse Events in Hospitals: Medicare's Responses to
Alleged Serious Events.
November 16, 2011
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; October 2011. Report No. OEI-01-08-00590.
https://psnet.ahrq.gov/issue/adverse-events-hospitals-medicares-response…
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psnet.ahrq.gov/node/47291/psn-pdf
October 31, 2018 - Incidence and method of suicide in hospitals in the United
States.
October 31, 2018
Williams SC, Schmaltz SP, Castro GM, et al. Incidence and Method of Suicide in Hospitals in the United
States. Jt Comm J Qual Patient Saf. 2018;44(11):643-650. doi:10.1016/j.jcjq.2018.08.002.
https://psnet.ahrq.gov/issue/incidence-…
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psnet.ahrq.gov/node/37648/psn-pdf
January 12, 2012 - Office surgery incidents: what seven years of Florida data
show us.
January 12, 2012
Coldiron BM, Healy C, Bene NI. Office surgery incidents: what seven years of Florida data show us.
Dermatol Surg. 2008;34(3):285-91; discussion 291-2. doi:10.1111/j.1524-4725.2007.34060.x.
https://psnet.ahrq.gov/issue/office-surge…
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - effectiveness of the confirmation process and lessens the
likelihood that effective communication occurs
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - checklists (it's a change, a possible slight increase in
time and effort, a bureaucratic exercise, etc.) occurs—until
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psnet.ahrq.gov/node/49420/psn-pdf
October 01, 2003 - To LP or Not LP
October 1, 2003
Landrigan CP. To LP or Not LP. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lp-or-not-lp
The Case
A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with
fever and irritability without an obvious source. He was referred to …
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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Patient Mix-Up
February 1, 2003
Shojania KG. Patient Mix-Up. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/patient-mix
The Case
Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general
medical service at an academic medical center. Overnight, another man wit…
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psnet.ahrq.gov/node/39402/psn-pdf
August 08, 2010 - The quest to eliminate intrathecal vincristine errors: a 40-
year journey.
August 8, 2010
Noble DJ, Donaldson LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf
Health Care. 2010;19(4):323-326. doi:10.1136/qshc.2008.030874.
https://psnet.ahrq.gov/issue/quest-eliminate-intratheca…
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psnet.ahrq.gov/node/37499/psn-pdf
January 10, 2017 - Medicare's decision to withhold payment for hospital
errors: the devil is in the details.
January 10, 2017
Wachter R, Foster NE, Dudley A. Medicare's decision to withhold payment for hospital errors: the devil is in
the det. Jt Comm J Qual Patient Saf. 2008;34(2):116-23.
https://psnet.ahrq.gov/issue/medicares-deci…
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psnet.ahrq.gov/node/37446/psn-pdf
January 06, 2017 - How useful are voluntary medication error reports? The
case of warfarin-related medication errors.
January 6, 2017
Zhan C, Smith SR, Keyes MA, et al. How useful are voluntary medication error reports? The case of
warfarin-related medication errors. Jt Comm J Qual Patient Saf. 2008;34(1):36-45.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/38675/psn-pdf
February 15, 2011 - Prescription errors and outcomes related to inconsistent
information transmitted through computerized order
entry: a prospective study.
February 15, 2011
Singh H, Mani S, Espadas D, et al. Prescription errors and outcomes related to inconsistent information
transmitted through computerized order entry: a prospecti…
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psnet.ahrq.gov/node/39193/psn-pdf
April 21, 2011 - Disclosing harmful mammography errors to patients.
April 21, 2011
Gallagher TH, Cook AJ, Brenner RJ, et al. Disclosing Harmful Mammography Errors to Patients. Radiology.
2009;253(2). doi:10.1148/radiol.2532082320.
https://psnet.ahrq.gov/issue/disclosing-harmful-mammography-errors-patients
Disclosing errors to pati…
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psnet.ahrq.gov/node/35927/psn-pdf
February 17, 2011 - Claims, errors, and compensation payments in medical
malpractice litigation.
February 17, 2011
Studdert DM, Mello MM, Gawande AA, et al. Claims, errors, and compensation payments in medical
malpractice litigation. N Engl J Med. 2006;354(19):2024-33.
https://psnet.ahrq.gov/issue/claims-errors-and-compensation-payme…
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - Pocket Syringe Swap
Citation Text:
Kulli JC. Pocket Syringe Swap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages
Citation Text:
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/36200/psn-pdf
February 15, 2011 - Choosing your words carefully: how physicians would
disclose harmful medical errors to patients.
February 15, 2011
Gallagher TH, Garbutt J, Waterman AD, et al. Choosing your words carefully: how physicians would
disclose harmful medical errors to patients. Arch Intern Med. 2006;166(15):1585-1593.
https://psnet.ahr…