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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/evaluation-automated-surveillance-system-using-trigger-alerts-prevent-adverse-drug-events
August 30, 2017 - Study
Evaluation of an automated surveillance system using trigger alerts to prevent adverse drug events in the intensive care unit and general ward.
Citation Text:
DiPoto JP, Buckley MS, Kane-Gill SL. Evaluation of an automated surveillance system using trigger alerts to prevent adverse…
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psnet.ahrq.gov/issue/exploring-roots-unintended-safety-threats-associated-introduction-hospital-eprescribing
December 21, 2022 - Study
Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative study.
Citation Text:
Mozaffar H, Cresswell K, Williams R, et al. Exploring the roots of unintended…
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psnet.ahrq.gov/issue/efficiency-and-thoroughness-trade-offs-high-volume-organisational-routines-ethnographic-study
June 14, 2017 - Study
Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of prescribing safety in primary care.
Citation Text:
Grant S, Guthrie B. Efficiency and thoroughness trade-offs in high-volume organisational routines: an ethnographic study of pre…
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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/use-electronic-clinical-decision-support-system-primary-care-assess-inappropriate
October 21, 2020 - Study
Use of an electronic clinical decision support system in primary care to assess inappropriate polypharmacy in young seniors with multimorbidity: observational, descriptive, cross-sectional study
Citation Text:
Rogero-Blanco E, Lopez-Rodriguez JA, Sanz-Cuesta T, et al. Use of an ele…
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psnet.ahrq.gov/issue/electronic-health-record-based-real-time-analytics-program-patient-safety-surveillance-and
May 19, 2018 - Study
An electronic health record–based real-time analytics program for patient safety surveillance and improvement.
Citation Text:
Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff …
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psnet.ahrq.gov/issue/good-care-slow-enough-be-able-pay-attention-primary-care-time-scarcity-and-patient-safety
August 04, 2015 - Study
"Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety.
Citation Text:
Satterwhite S, Nguyen M-LT, Honcharov V, et al. "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. J Gen Intern …
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psnet.ahrq.gov/issue/sustained-user-engagement-health-information-technology-long-road-implementation-system
December 21, 2022 - Study
Sustained user engagement in health information technology: the long road from implementation to system optimization of computerized physician order entry and clinical decision support systems for prescribing in hospitals in England.
Citation Text:
Cresswell K, Lee L, Mozaffar H, e…
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psnet.ahrq.gov/issue/safety-risks-associated-lack-integration-and-interfacing-hospital-health-information
December 21, 2022 - Study
Safety risks associated with the lack of integration and interfacing of hospital health information technologies: a qualitative study of hospital electronic prescribing systems in England.
Citation Text:
Cresswell K, Mozaffar H, Lee L, et al. Safety risks associated with the lack o…
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psnet.ahrq.gov/issue/drug-drug-interactions-and-actual-harm-hospitalized-patients-multicentre-study-examining
August 26, 2020 - Study
Drug-drug interactions and actual harm to hospitalized patients: a multicentre study examining the prevalence pre- and post-electronic medication system implementation.
Citation Text:
Li L, Baker J, Quirk R, et al. Drug-drug interactions and actual harm to hospitalized patients: a …
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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/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/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/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