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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33711/psn-pdf
    May 01, 2011 - relationship between the patient and caregiver, length of professional relationships, cases that involved pediatric

  2. Handoffs and Transitions | PSNet

    psnet.ahrq.gov/perspective/handoffs-and-transitions
    February 01, 2007 - The implementation of I-PASS in nine pediatric residency programs required adoption of the tool and guidelines

  3. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital | PSNet

    psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
    May 16, 2022 - Association between mobile telephone interruptions and medication administration errors in a pediatric

  4. Walking Out of a Hospital After Attempted Suicide | PSNet

    psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
    March 29, 2023 - Departments Physicians Emergency Medicine Mental Health Care (Psychiatry and Clinical Psychology) Pediatric

  5. Inadvertent Castration | PSNet

    psnet.ahrq.gov/web-mm/inadvertent-castration
    October 27, 2010 - March 27, 2024 Priorities for pediatric patient safety research.

  6. Medication Reconciliation Pitfalls | PSNet

    psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
    May 01, 2006 - Order March 1, 2019 Comparing errors in ED computer-assisted vs conventional pediatric

  7. Undiagnosed Vaginal Bleeding | PSNet

    psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
    July 06, 2022 - April 7, 2022 Reliability and usability of a 7-minute chart review tool to identify pediatric

  8. A Mid-Summer Fog | PSNet

    psnet.ahrq.gov/web-mm/mid-summer-fog
    September 29, 2017 - March 12, 2011 Enhancing pediatric safety: assessing and improving resident competency

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852807/psn-pdf
    August 30, 2023 - At least among pediatric residents, the total number of hours of work and sleep, the overall medication

  10. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia | PSNet

    psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
    January 29, 2021 - At least among pediatric residents, the total number of hours of work and sleep, the overall medication

  11. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations | PSNet

    psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
    September 27, 2023 - increased from 3.9% to 37.8% between 1997 and 2016. 3 There are circumstances, such as those involving pediatric

  12. 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 - April 12, 2023 Systematic review of medication errors in pediatric patients.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857059/psn-pdf
    November 29, 2023 - The Risks of a Malpositioned Gastrostomy Tube and Poor Communication November 29, 2023 Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication Disclosure of Relevant Financial …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49514/psn-pdf
    July 01, 2006 - One ACE Too Many July 1, 2006 Juurlink DN. One ACE Too Many. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/one-ace-too-many The Case A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure presented to the emergency department (ED) with chest pain. An acut…

  15. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
    February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49469/psn-pdf
    December 01, 2004 - Overriding Considerations December 1, 2004 Holtzman NA. Overriding Considerations. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/overriding-considerations The Case Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic testing for a variety of condition…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33868/psn-pdf
    October 01, 2018 - Safety in the Retail Pharmacy October 1, 2018 Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/safety-retail-pharmacy Perspective There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each year.(1) Many patients interact w…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33679/psn-pdf
    January 01, 2009 - Disclosure of Medical Error January 1, 2009 Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/disclosure-medical-error Perspective Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater discl…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49773/psn-pdf
    July 01, 2016 - Near Miss With Neonate October 1, 2016 Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/near-miss-neonate The Case A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxy…

  20. 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…
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