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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - Sleep Deprivation Leads to Medication Error During
Spinal Epidural Anesthesia
August 30, 2023
Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-…
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
July 30, 2020 - Co-Editor-in-Chief, AHRQ's Patient Safety Network (PSNet) Professor Departments of General Medicine and Pediatrics
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psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
September 01, 2008 - Drug libraries may be unit specific, with unique rules for individual clinical areas such as pediatrics
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psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
September 01, 2008 - Drug libraries may be unit specific, with unique rules for individual clinical areas such as pediatrics
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - For example, I never talked to surgery or pediatrics or some of the other specialties when we launched
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - Pediatrics. 2016;138(6). [Available at]
30. Douglass AM, Elder J, Watson R, et al.
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psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
January 31, 2024 - This error particularly happens more frequently in pediatrics, where you have weight-based dosing.
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psnet.ahrq.gov/web-mm/comanagement-whos-charge
July 01, 2011 - Comanagement: Who's in Charge?
Citation Text:
Cheng HQ. Comanagement: Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
July 01, 2003 - DNR in the OR and Afterwards
Citation Text:
Lo B. DNR in the OR and Afterwards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/pca-overdose
April 01, 2017 - PCA Overdose
Citation Text:
Doyle JD. PCA Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - Cups of Error
Citation Text:
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/49586/psn-pdf
May 01, 2009 - Vial Mistakes Involving Heparin
May 1, 2009
Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
The Case
A 65-year-old man was admitted to the hospital for an elective left carotid endarterectomy. During the
procedure, the surgeon re…
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psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/node/49709/psn-pdf
May 01, 2014 - Raise the Bar
May 1, 2014
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/raise-bar
The Case
A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The
patient was seen and evaluated by an anesthesiologist who was new to the cente…
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psnet.ahrq.gov/node/33880/psn-pdf
May 01, 2019 - Safety in the Prehospital Emergency Medical Services
Setting
May 1, 2019
Patterson DP, Yealy DM. Safety in the Prehospital Emergency Medical Services Setting. PSNet [internet].
2019.
https://psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
Perspective
Emergency medical services (E…
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psnet.ahrq.gov/web-mm/missed-tb
March 03, 2010 - Missed TB
Citation Text:
FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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psnet.ahrq.gov/node/49782/psn-pdf
January 01, 2017 - A Potent Medication Administered in a Not So Viable
Route
January 1, 2017
Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
The Case
A 55-year-old man with history of nonischemic cardiomyop…
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psnet.ahrq.gov/node/49622/psn-pdf
March 01, 2011 - Dropping the Ball Despite an Integrated EMR
March 1, 2011
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
The Case
A patient followed at a community-based clinic that is part of a large health care system with an
in…