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psnet.ahrq.gov/issue/farewell-cancer-never-was
April 12, 2011 - Commentary
Farewell to a cancer that never was.
Citation Text:
Lyon J. Farewell to a Cancer That Never Was. JAMA. 2017;317(18):1824-1825. doi:10.1001/jama.2017.3969.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/issue/inpatient-computerized-provider-order-entry-findings-ahrq-health-it-portfolio
May 24, 2015 - Book/Report
Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio.
Citation Text:
Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio. Dixon BE, Zafar A, for AHRQ National Resource Center for Health IT. Rockville, MD: …
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psnet.ahrq.gov/issue/health-literacy-toolkit
February 22, 2023 - Toolkit
Health Literacy Toolkit.
Citation Text:
Health Literacy Toolkit. Leeds, UK: Health Education England, Public Health England, NHS England and Community Health and Learning Foundation; December 11, 2017.
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psnet.ahrq.gov/node/865570/psn-pdf
April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program:
Applying a Proactive Approach With Data Review &
Collaborating With a Second Practitioner
April 10, 2024
https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-
approach-data
Summary
North American Partners…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
March 01, 2012 - Spotlight Case July 2008
Spotlight Case
Postdischarge Follow-Up Phone Call
*
*
Source and Credits
This presentation is based on the March 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Michelle Mourad, MD, and Stephanie Rennke, MD; Divi…
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/primers-0
March 15, 2025 - Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Latest Primers
Clinical Decision Support Systems
March…
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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - Mistaken Identity
October 1, 2008
Hall LW. Mistaken Identity. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mistaken-identity
The Case
An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status
and a reported fall. After finding tenderness in her left hip, the p…
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psnet.ahrq.gov/node/49502/psn-pdf
February 01, 2006 - Deciphering the Code
February 1, 2006
Goldstein MK. Deciphering the Code. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/deciphering-code
The Case
An 85-year-old man with advanced oxygen-dependent chronic obstructive pulmonary disease (COPD)
presented to the emergency department (ED) with increasing shortn…
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE
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Apri…
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psnet.ahrq.gov/node/50699/psn-pdf
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
Background
Older patients are at a particular risk of experiencing a patient safety event. Stud…
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - Alert Fatigue
Citation Text:
Alert Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Ci…
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psnet.ahrq.gov/node/45117/psn-pdf
August 03, 2016 - Using computerized prescriber order entry to limit
overrides from automated dispensing cabinets.
August 3, 2016
Drake E, Srinivas P, Trujillo T. Using computerized prescriber order entry to limit overrides from automated
dispensing cabinets. Am J Health-Syst Pharm. 2016;73(14):1033-1035. doi:10.2146/ajhp150564.
ht…
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psnet.ahrq.gov/node/46007/psn-pdf
July 09, 2018 - A family-centered rounds checklist, family engagement,
and patient safety: a randomized trial.
July 9, 2018
Cox E, Jacobsohn GC, Rajamanickam VP, et al. A Family-Centered Rounds Checklist, Family
Engagement, and Patient Safety: A Randomized Trial. Pediatrics. 2017;139(5). doi:10.1542/peds.2016-
1688.
https://psne…
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psnet.ahrq.gov/node/41028/psn-pdf
May 14, 2018 - Health care worker fatigue and patient safety.
May 14, 2018
Sentinel Event Alert. December 14, 2011;(48):1-4. (addendum May 14, 2018).
https://psnet.ahrq.gov/issue/health-care-worker-fatigue-and-patient-safety
The Joint Commission issues sentinel event alerts to emphasize pressing safety issues and provide
guideli…
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psnet.ahrq.gov/node/46584/psn-pdf
December 06, 2017 - Alterations in Spanish language interpretation during
pediatric critical care family meetings.
December 6, 2017
Sinow CS, Corso I, Lorenzo J, et al. Alterations in Spanish Language Interpretation During Pediatric Critical
Care Family Meetings. Crit Care Med. 2017;45(11):1915-1921. doi:10.1097/CCM.0000000000002650.
…
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psnet.ahrq.gov/node/73214/psn-pdf
May 05, 2021 - Patient and physician perspectives of deprescribing
potentially inappropriate medications in older adults with
a history of falls: a qualitative study.
May 5, 2021
Hahn EE, Munoz-Plaza CE, Lee EA, et al. Patient and physician perspectives of deprescribing potentially
inappropriate medications in older adults with …
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psnet.ahrq.gov/node/45392/psn-pdf
August 17, 2016 - Boosting medical diagnostics by pooling independent
judgments.
August 17, 2016
Kurvers RHJM, Herzog SM, Hertwig R, et al. Boosting medical diagnostics by pooling independent
judgments. Proc Natl Acad Sci U S A. 2016;113(31):8777-8782. doi:10.1073/pnas.1601827113.
https://psnet.ahrq.gov/issue/boosting-medical-diagn…
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psnet.ahrq.gov/node/47769/psn-pdf
May 11, 2019 - Avoiding chemotherapy prescribing errors: analysis and
innovative strategies.
May 11, 2019
Reinhardt H, Otte P, Eggleton AG, et al. Avoiding chemotherapy prescribing errors: Analysis and innovative
strategies. Cancer. 2019;125(9):1547-1557. doi:10.1002/cncr.31950.
https://psnet.ahrq.gov/issue/avoiding-chemotherapy…
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psnet.ahrq.gov/node/44648/psn-pdf
February 14, 2017 - Rising drug allergy alert overrides in electronic health
records: an observational retrospective study of a decade
of experience.
February 14, 2017
Topaz M, Seger DL, Slight SP, et al. Rising drug allergy alert overrides in electronic health records: an
observational retrospective study of a decade of experience. …