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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. 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. …
  5. Psn-Pdf (pdf file)

    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…
  6. 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…
  7. 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…
  8. 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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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 …
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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