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psnet.ahrq.gov/issue/workarounds-hospital-electronic-prescribing-systems-qualitative-study-english-hospitals
December 21, 2022 - Study
Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals.
Citation Text:
Cresswell K, Mozaffar H, Lee L, et al. Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals. BMJ Qual Saf. 2017;26(7):542-551…
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psnet.ahrq.gov/issue/health-disparities-impact-health-disparities-and-treatment-decision-making-biases-cancer
October 14, 2020 - Commentary
Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse effects among black cancer survivors.
Citation Text:
Vo J, Gillman A, Mitchell K, et al. Health disparities: impact of health disparities and treatment decision-making biase…
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psnet.ahrq.gov/issue/methods-studying-medication-safety-following-electronic-health-record-implementation-acute
February 03, 2011 - Review
Methods for studying medication safety following electronic health record implementation in acute care: a scoping review.
Citation Text:
Pereira N, Duff JP, Hayward T, et al. Methods for studying medication safety following electronic health record implementation in acute care: a …
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psnet.ahrq.gov/issue/association-label-drug-use-and-adverse-drug-events-adult-population
February 03, 2011 - Study
Classic
Association of off-label drug use and adverse drug events in an adult population.
Citation Text:
Eguale T, Buckeridge DL, Verma A, et al. Association of Off-label Drug Use and Adverse Drug Events in an Adult Population. JAMA Intern Med. 2016;176(1)…
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psnet.ahrq.gov/issue/investigating-impact-pharmacist-intervention-inappropriate-prescribing-practices-hospital
November 30, 2022 - Study
Investigating the impact of a pharmacist intervention on inappropriate prescribing practices at hospital admission and discharge in older patients: a secondary outcome analysis from a randomized controlled trial.
Citation Text:
Garcia BH, Omma KK, Småbrekke L, et al. Investigating …
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psnet.ahrq.gov/issue/health-economic-evaluation-infection-prevention-and-control-program-are-quality-and-patient
June 02, 2021 - Study
Health economic evaluation of an infection prevention and control program: are quality and patient safety programs worth the investment?
Citation Text:
Raschka S, Dempster L, Bryce E. Health economic evaluation of an infection prevention and control program: are quality and patien…
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psnet.ahrq.gov/issue/clinical-decision-support-systems-could-be-modified-reduce-alert-fatigue-while-still
December 21, 2022 - Commentary
Clinical decision support systems could be modified to reduce 'alert fatigue' while still minimizing the risk of litigation.
Citation Text:
Kesselheim AS, Cresswell K, Phansalkar S, et al. Clinical decision support systems could be modified to reduce 'alert fatigue' while stil…
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psnet.ahrq.gov/node/33759/psn-pdf
October 01, 2012 - These services may include diagnosis, treatment, surgery, and rehabilitation and
span medical offices, community … pharmacies, diagnostic laboratories, emergency departments, outpatient
surgery centers, home health
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - 2008
Effect of a central call center on employee perceptions of safety culture within community … pharmacies in an academic health system.
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psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
September 01, 2011 - Is the Admission Drug Dose Too Low?
Citation Text:
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/node/49476/psn-pdf
March 02, 2005 - Around the Block
March 1, 2005
Minichiello T. Around the Block. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/around-block
The Case
A 77-year-old woman with multiple medical problems was admitted to the hospital for an elective knee
replacement. The orthopedic surgeon, recognizing the risk of deep vein th…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
December 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case December 2006
Hidden Heparins: HIT Happens
Source and Credits
This presentation is based on the December 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrick F. Fogarty,…
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psnet.ahrq.gov/node/49718/psn-pdf
January 01, 2015 - Too Much, Too Fast
September 1, 2014
Tuot D. Too Much, Too Fast. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/too-much-too-fast
The Case
A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for
fever, tachycardia, and increased respiratory secretions. H…
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psnet.ahrq.gov/training-catalog
June 01, 2025 - Training Catalog
The AHRQ PSNet Training Catalog is an easy to use resource for healthcare professionals across all settings of care and specialties looking for education opportunities to further their knowledge of patient safety practices and principles. Some training opportunities are available as in-person meeting…
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psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room
January 29, 2021 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room.
Citation Text:
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
April 10, 2024 - 75 The federal government, states, and territories partnered with multiple national and independent pharmacies … The pharmacies facilitated vaccinations for NH residents and staff at no cost to the NHs. 76 The CDC
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - SPOTLIGHT CASE
Antiseizure Medication Disorder
Citation Text:
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such …
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - SPOTLIGHT CASE
A Fatal Twist in Pseudohyperkalemia
Citation Text:
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
…
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psnet.ahrq.gov/node/49690/psn-pdf
September 01, 2013 - prescription drug monitoring program including appropriate information from
all the physicians and pharmacies