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psnet.ahrq.gov/node/34890/psn-pdf
February 17, 2011 - Electronic alerts to prevent venous thromboembolism
among hospitalized patients.
February 17, 2011
Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized
patients. N Engl J Med. 2005;352(10):969-77.
https://psnet.ahrq.gov/issue/electronic-alerts-prevent-venous-thro…
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - Another option is to construct a manometer with a 20-cm to 30-cm piece of sterile IV tubing flushed with … Sending a venous blood sample for gas analysis is another option.
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psnet.ahrq.gov/node/47024/psn-pdf
November 28, 2018 - FDA Safety Communication: use caution with implanted
pumps for intrathecal administration of medicines for
pain management.
November 28, 2018
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; November 14, 2018.
https://psnet.ahrq.gov/issue/fda-safety-communication-use-caution-implanted-pum…
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psnet.ahrq.gov/node/45455/psn-pdf
June 29, 2017 - JAMA professionalism: disclosure of medical error.
June 29, 2017
Levinson W, Yeung J, Ginsburg S. Disclosure of Medical Error. JAMA. 2016;316(7):764-5.
doi:10.1001/jama.2016.9136.
https://psnet.ahrq.gov/issue/jama-professionalism-disclosure-medical-error
Disclosing medical errors to patients is essential for maint…
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psnet.ahrq.gov/node/44579/psn-pdf
September 01, 2016 - Increased appropriateness of customized alert
acknowledgement reasons for overridden medication
alerts in a computerized provider order entry system.
September 1, 2016
Dekarske BM, Zimmerman CR, Chang R, et al. Increased appropriateness of customized alert
acknowledgement reasons for overridden medication alerts i…
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psnet.ahrq.gov/node/837424/psn-pdf
June 15, 2022 - Allergy safety events in healthcare: development and
application of a classification schema based on
retrospective review.
June 15, 2022
Phadke NA, Wickner PG, Wang L, et al. Allergy safety events in healthcare: development and application
of a classification schema based on retrospective review. J Allergy Clin Im…
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psnet.ahrq.gov/node/60837/psn-pdf
August 26, 2020 - Attending to the emotional well-being of the health care
workforce in a New York City health system during the
COVID-19 pandemic.
August 26, 2020
Ripp JA, Peccoralo L, Charney D. Attending to the emotional well-being of the health care workforce in a
New York City health system during the COVID-19 pandemic. Acad M…
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psnet.ahrq.gov/node/33733/psn-pdf
July 01, 2012 - Patient Safety and Health Information Technology:
Learning from Our Mistakes
July 1, 2012
Koppel R. Patient Safety and Health Information Technology: Learning from Our Mistakes. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
Perspe…
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psnet.ahrq.gov/node/34704/psn-pdf
December 24, 2008 - Negligent care and malpractice claiming behavior in Utah
and Colorado.
December 24, 2008
Studdert DM, Thomas EJ, Burstin HR, et al. Negligent care and malpractice claiming behavior in Utah and
Colorado. Med Care. 2000;38(3):250-60.
https://psnet.ahrq.gov/issue/negligent-care-and-malpractice-claiming-behavior-utah-…
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psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - they can still have rational reasons
specific to their own preferences for forgoing the recommended option
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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psnet.ahrq.gov/node/49539/psn-pdf
June 01, 2007 - being emergently required for the patient, or general anesthesia having been discussed as a
treatment option
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
December 01, 2009 - was ambulating at that point, he still required additional IV antibiotics and still lacked any viable option
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psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - The Hazards of Distraction: Ticking All the EHR Boxes
February 1, 2017
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
Case Objectives
List the goals of having order sets in the electronic health record…
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - A final comprehensive system option is the development of team-based patient navigation
services, as
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psnet.ahrq.gov/node/39581/psn-pdf
January 03, 2017 - An implementation strategy for a multicenter pediatric
rapid response system in Ontario.
January 3, 2017
Buist MD, Shearer W. Rapid Response Systems: A Mandatory System of Care or an Optional Extra for
Bedside Clinical Staff? The Joint Commission Journal on Quality and Patient Safety. 2016;36(6).
doi:10.1016/s1553…
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psnet.ahrq.gov/issue/ihi-announces-hospitals-participating-100000-lives-campaign-have-saved-estimated-122300-lives
August 07, 2024 - Press Release/Announcement
Classic
IHI announces that hospitals participating in 100,000 Lives Campaign have saved an estimated 122,300 lives.
Save
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psnet.ahrq.gov/node/47579/psn-pdf
December 12, 2018 - A prescription for enhancing electronic prescribing
safety.
December 12, 2018
Schiff G, Mirica MM, Dhavle AA, et al. A Prescription For Enhancing Electronic Prescribing Safety. Health
Aff (Millwood). 2018;37(11):1877-1883. doi:10.1377/hlthaff.2018.0725.
https://psnet.ahrq.gov/issue/prescription-enhancing-electroni…
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psnet.ahrq.gov/node/49790/psn-pdf
April 01, 2017 - allergic reaction from adverse drug reactions,
then appropriate use of these codes is the most suitable option
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psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia
January 1, 2019
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
The Case
A 72-year-old woman with a history of severe peripheral vascular dis…