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psnet.ahrq.gov/issue/missed-nursing-care-concept-analysis
January 19, 2022 - Commentary
Missed nursing care: a concept analysis.
Citation Text:
Kalisch BJ, Landstrom GL, Hinshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65(7):1509-17. doi:10.1111/j.1365-2648.2009.05027.x.
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psnet.ahrq.gov/issue/intrathecal-chemotherapy-potential-medication-error
February 23, 2015 - Review
Intrathecal chemotherapy: potential for medication error.
Citation Text:
Gilbar PJ. Intrathecal chemotherapy: potential for medication error. Cancer Nurs. 2014;37(4):299-309. doi:10.1097/NCC.0000000000000108.
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DOI Google Scholar PubMed BibTeX End…
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psnet.ahrq.gov/issue/dual-process-cognitive-interventions-enhance-diagnostic-reasoning-systematic-review
March 20, 2019 - Review
Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review.
Citation Text:
Lambe KA, O'Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf. 2016;25(10):808-820. doi:10.113…
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psnet.ahrq.gov/issue/impact-hospital-accreditation-quality-improvement-healthcare-systematic-review
September 23, 2020 - Review
Impact of hospital accreditation on quality improvement in healthcare: a systematic review.
Citation Text:
Alhawajreh MJ, Paterson AS, Jackson WJ. Impact of hospital accreditation on quality improvement in healthcare: a systematic review. PLoS ONE. 2023;18(12):e0294180. doi:10.137…
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psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - Patient Allergies and Electronic Health Records
Citation Text:
Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/866217/psn-pdf
July 10, 2024 - In Conversation With...Amy Helwig about Health Plan
Patient Safety Initiatives
July 10, 2024
Helwig A, Sousane Z, Mossburg S. In Conversation With..Amy Helwig about Health Plan Patient Safety
Initiatives. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patie…
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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - One ACE Too Many
July 1, 2006
Juurlink DN. One ACE Too Many. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/one-ace-too-many
The Case
A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure
presented to the emergency department (ED) with chest pain. An acut…
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psnet.ahrq.gov/web-mm/outpatient-zebra
January 23, 2020 - An Outpatient 'Zebra'
Citation Text:
Berkowitz L. An Outpatient 'Zebra'. 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/49484/psn-pdf
June 01, 2005 - The epidemiology of prescribing
errors: the potential impact of computerized prescriber order entry.
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psnet.ahrq.gov/print/pdf/node/74277
January 01, 2021 - This commentary suggests strategies for improving prescribing safety, including linking pharmacy and
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - October 31, 2014
Potentially inappropriate prescribing for elderly patients in 2 outpatient … December 16, 2020
WebM&M Cases
E-prescribing: E for error
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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - replace it with
errors associated with picking the wrong item in a drop-down list, which may result in prescribing … the wrong
drug, dose, or route of a medication; prescribing to the wrong patient; or selecting the
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psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
November 13, 2024 - October 25, 2023
Safer prescribing for hospitalized older adults with an electronic health … records‐based prescribing context.
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psnet.ahrq.gov/node/49758/psn-pdf
April 01, 2016 - Protocol-driven and evidence-based order sets for specific clinical scenarios can
help standardize insulin prescribing … In addition, the commentary described building a
mechanism (presumably electronically) where the prescribing
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - i.e., a medication history, or pre-admission medication
list [PAML]) and comparing that list to the prescribing … Comparing the PAML to the prescribing clinician’s admission,
transfer, and discharge orders would have
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psnet.ahrq.gov/curated-library/value-and-patient-safety
October 30, 2019 - prior data on changes in adverse drug event rates both before and after implementation of electronic prescribing … These data support further implementation of electronic prescribing, despite concerns about introducing
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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - this case included: (i) not viewing or checking the patient's complete medication history before prescribing
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - The safe prescribing and monitoring of antiseizure drugs are challenging for several reasons: There … widespread clinical pharmacist coverage might do well by considering targeted coverage in high-risk prescribing
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psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - Safety I, Safety II, and the New Views of Safety
February 26, 2025
Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
Background and Context
Safety I and Safety II (Safety I/II) are not safety method…
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - Safety I, Safety II, and the New Views of Safety
Citation Text:
Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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