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psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - Looking for Meds in All the Wrong Places
October 1, 2012
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
The Case
A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She
went to t…
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psnet.ahrq.gov/node/49412/psn-pdf
September 01, 2003 - Shake Well
September 1, 2003
Flynn EA. Shake Well. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/shake-well
The Case
A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily
serum drug levels consistently fell below the therapeutic range, which led the physi…
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psnet.ahrq.gov/node/49421/psn-pdf
October 01, 2003 - Urine a Tough Position
October 1, 2003
Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/urine-tough-position
The Case
A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although
she did not want to have a baby at that time, she sta…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
June 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case June 2004
The Wrong Shot:
Error Disclosure
Source and Credits
This presentation is based on the June 2004
AHRQ WebM&M Spotlight Case in Pediatrics
CME credit is available through the Web site
See the full article at http://webmm.ahrq.gov
Commentary by: Thomas H. …
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psnet.ahrq.gov/node/33655/psn-pdf
August 01, 2007 - The PeaceHealth Governance Journey in Support of
Quality and Safety
August 1, 2007
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
Perspective
In recent years, the…
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psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
December 01, 2005 - Introducing the Redesigned AHRQ Patient Safety Network
Robert M. Wachter, MD | November 1, 2015
View more articles from the same authors.
Citation Text:
Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/primer/surgical-site-infections
December 15, 2024 - Surgical Site Infections
Citation Text:
Surgical Site Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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psnet.ahrq.gov/node/44065/psn-pdf
July 16, 2015 - Nurses' use of computerized clinical guidelines to
improve patient safety in hospitals.
July 16, 2015
Hovde B, Jensen KH, Alexander GL, et al. Nurses' Use of Computerized Clinical Guidelines to Improve
Patient Safety in Hospitals. West J Nurs Res. 2015;37(7):877-98. doi:10.1177/0193945915577430.
https://psnet.ahrq…
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psnet.ahrq.gov/node/74194/psn-pdf
December 15, 2021 - Age-related COVID-19 vaccine mix-ups.
December 15, 2021
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. December 6, 2021.
https://psnet.ahrq.gov/issue/age-related-covid-19-vaccine-mix-ups
Vaccine missteps are known to …
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psnet.ahrq.gov/node/43579/psn-pdf
October 08, 2014 - Implications of Health Literacy for Public Health:
Workshop Summary.
October 8, 2014
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health
Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/47738/psn-pdf
February 06, 2019 - ISMP Guidelines for Safe Electronic Communication of
Medication Information.
February 6, 2019
Horsham, PA: Institute for Safe Medication Practices; January 2019.
https://psnet.ahrq.gov/issue/ismp-guidelines-safe-electronic-communication-medication-information
Inaccurate or incomplete data in electronic health reco…
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psnet.ahrq.gov/node/47393/psn-pdf
November 28, 2018 - Still Failing the Frail.
November 28, 2018
Simmons-Ritchie D. Penn Live. November 15, 2018.
https://psnet.ahrq.gov/issue/still-failing-frail
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing
levels, lack of regulation enforcement, and misaligned financial in…
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psnet.ahrq.gov/node/846164/psn-pdf
March 15, 2023 - Crowding in the Emergency Department: Challenges for
the Care of Children.
March 15, 2023
Gross TK, Lane NE, Timm NL, et al. Crowding in the Emergency Department: Challenges for the Care of
Children. Pediatrics. 2023;151(3):e2022060971-e2022060972. doi:10.1542/peds.2022-060971.
https://psnet.ahrq.gov/issue/crowdin…
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psnet.ahrq.gov/node/836969/psn-pdf
April 20, 2022 - Criminalization of human error and a guilty verdict: a
travesty of justice that threatens patient safety.
April 20, 2022
ISMP Medication Safety Alert! Acute care edition. April 7, 2022; 27(2):1-6.
https://psnet.ahrq.gov/issue/criminalization-human-error-and-guilty-verdict-travesty-justice-threatens-
patient-safety…
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psnet.ahrq.gov/node/73178/psn-pdf
April 28, 2021 - Risk perception on the labour ward: a mixed methods
study.
April 28, 2021
McCarthy C, Meaney S, Rochford M, et al. Risk perception on the labour ward: a mixed methods study. J
Patient Saf Risk Manag. 2021;26(2):56-63. doi:10.1177/25160435211002428.
https://psnet.ahrq.gov/issue/risk-perception-labour-ward-mixed-met…
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psnet.ahrq.gov/node/46836/psn-pdf
February 21, 2018 - Drone delivery of medications: review of the landscape
and legal considerations.
February 21, 2018
Lin CA, Shah K, Mauntel LCC, et al. Drone delivery of medications: Review of the landscape and legal
considerations. Am J Health Syst Pharm. 2018;75(3):153-158. doi:10.2146/ajhp170196.
https://psnet.ahrq.gov/issue/dr…
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psnet.ahrq.gov/node/867700/psn-pdf
March 01, 2023 - Toolkit for Reducing Central Line-Associated Blood
Stream Infections.
March 1, 2023
Agency for Healthcare Research and Quality. Toolkit for Reducing Central Line-Associated Blood Stream
Infections. March 2023.
https://psnet.ahrq.gov/issue/toolkit-reducing-central-line-associated-blood-stream-infections
Eliminatin…
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psnet.ahrq.gov/node/46278/psn-pdf
July 19, 2017 - The opioid epidemic: what can surgeons do about it?
July 19, 2017
Saluja S, Selzer D, Meara JG, et al. Bull Am Coll Surg. 2017;102(7):13-18.
https://psnet.ahrq.gov/issue/opioid-epidemic-what-can-surgeons-do-about-it
Surgeons often prescribe opioids for patients after procedures, so they are in a key position to ass…
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psnet.ahrq.gov/node/47459/psn-pdf
October 10, 2018 - People, processes, health IT and accurate patient
identification.
October 10, 2018
Quick Safety. October 1, 2018;(45):1-2.
https://psnet.ahrq.gov/issue/people-processes-health-it-and-accurate-patient-identification
This newsletter article reviews common problems related to patient identification and recommends
st…