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psnet.ahrq.gov/node/49764/psn-pdf
June 01, 2016 - Communication With Consultants
June 1, 2016
Cohn SL. Communication With Consultants. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/communication-consultants
The Case
A 30-year-old pregnant woman presented to the emergency department (ED) with nausea, headaches, and
fevers. Her laboratory studies were nota…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Bad Writing, Wrong Medication
*
*
Source and Credits
This presentation is based on the April 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Beth Devine, PharmD, MBA, PhD
University of Washingto…
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psnet.ahrq.gov/node/49603/psn-pdf
June 01, 2010 - Fatal Error in Neonate: Does "Just Culture" Provide an
Answer?
June 1, 2010
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
Case Objectives
Describe the just culture approach to in…
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psnet.ahrq.gov/node/49496/psn-pdf
December 01, 2005 - Discharged Blindly
December 1, 2005
Iezzoni LI. Discharged Blindly. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharged-blindly
The Case
An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to
receive enoxaparin (Lovenox) for self-administration at home…
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psnet.ahrq.gov/node/38677/psn-pdf
August 18, 2010 - Impact of a computerized physician order-entry system.
August 18, 2010
Stone WM, Smith BE, Shaft JD, et al. Impact of a computerized physician order-entry system. J Am Coll
Surg. 2009;208(5):960-7; discussion 967-9. doi:10.1016/j.jamcollsurg.2009.01.042.
https://psnet.ahrq.gov/issue/impact-computerized-physician-or…
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psnet.ahrq.gov/node/36456/psn-pdf
May 27, 2011 - Evaluation and certification of computerized physician
order entry systems.
May 27, 2011
Classen D, Avery A, Bates DW. Evaluation and certification of computerized provider order entry systems.
J Am Med Inform Assoc. 2007;14(1):48-55.
https://psnet.ahrq.gov/issue/evaluation-and-certification-computerized-physician…
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psnet.ahrq.gov/node/39811/psn-pdf
September 13, 2010 - Disclosure of medical errors: the right thing to do.
September 13, 2010
Schuer KM, AAPA QCC of the. Disclosure of medical errors: the right thing to do. JAAPA. 2010;23(8):27-9.
https://psnet.ahrq.gov/issue/disclosure-medical-errors-right-thing-do
This article discusses medical error disclosure, provides evidence of…
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psnet.ahrq.gov/node/39766/psn-pdf
August 18, 2010 - Paediatric dosing errors before and after electronic
prescribing.
August 18, 2010
Jani Y, Barber N, Wong ICK. Paediatric dosing errors before and after electronic prescribing. Qual Saf
Health Care. 2010;19(4):337-40. doi:10.1136/qshc.2009.033068.
https://psnet.ahrq.gov/issue/paediatric-dosing-errors-and-after-elec…
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psnet.ahrq.gov/node/37450/psn-pdf
June 13, 2011 - Technical patient safety solutions for medicines
reconciliation on admission of adults to hospital.
June 13, 2011
Manchester, UK: National Institute for Health and Clinical Excellence; 2015.
https://psnet.ahrq.gov/issue/technical-patient-safety-solutions-medicines-reconciliation-admission-adults-
hospital
This gu…
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psnet.ahrq.gov/node/34596/psn-pdf
February 17, 2009 - Disclosure: what works now and what can work even
better (part 3 of 3).
February 17, 2009
Chicago, IL: American Society of Healthcare Risk Management;
https://psnet.ahrq.gov/issue/disclosure-what-works-now-and-what-can-work-even-better-part-3-3
A guide for communicating throughout the disclosure process, thi…
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psnet.ahrq.gov/node/42268/psn-pdf
May 15, 2013 - Clinical pharmacy interventions in paediatric electronic
prescriptions.
May 15, 2013
Maat B, San Au Y, Bollen CW, et al. Clinical pharmacy interventions in paediatric electronic prescriptions.
Arch Dis Child. 2013;98(3):222-7. doi:10.1136/archdischild-2012-302817.
https://psnet.ahrq.gov/issue/clinical-pharmacy-int…
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psnet.ahrq.gov/node/33827/psn-pdf
February 01, 2017 - New Insights About Team Training From a Decade of
TeamSTEPPS
February 1, 2017
Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
Perspective
Ten years ago, the Ag…
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psnet.ahrq.gov/node/36065/psn-pdf
May 27, 2011 - Passing the "Yo' Mama" test.
May 27, 2011
Blair R. Passing the "Yo' Mama" test. Atlanta healthcare organization follows the beat of a different
drummer in achieving 100 percent CPOE adoption. Health Manag Technol. 2006;27(6):14, 16, 18.
https://psnet.ahrq.gov/issue/passing-yo-mama-test
This article discusses how a…
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psnet.ahrq.gov/node/50405/psn-pdf
October 02, 2019 - Nurses and patients: natural partners to advance patient
safety
October 2, 2019
Ricciardi R, Shofer M. Nurses and Patients: Natural Partners to Advance Patient Safety. J Nurs Care Qual.
2019;34(1):1-3. doi:10.1097/NCQ.0000000000000377.
https://psnet.ahrq.gov/issue/nurses-and-patients-natural-partners-advance-patie…
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psnet.ahrq.gov/node/38015/psn-pdf
August 27, 2008 - Impact of electronic prescribing in a hospital setting: a
process-focused evaluation.
August 27, 2008
Cunningham TR, Geller S, Clarke SW. Impact of electronic prescribing in a hospital setting: a process-
focused evaluation. Int J Med Inform. 2008;77(8):546-54.
https://psnet.ahrq.gov/issue/impact-electronic-presc…
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psnet.ahrq.gov/web-mm/near-miss-neonate
August 15, 2018 - Near Miss With Neonate
Citation Text:
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/node/50612/psn-pdf
October 30, 2019 - The Safety Challenges of Supervision and Night Coverage
in Academic Residency
October 30, 2019
Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
The Case…
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psnet.ahrq.gov/node/846127/psn-pdf
March 15, 2023 - Sepsis Resulting from Delays in Treatment and
Miscommunication among Specialists
March 15, 2023
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-
spec…
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Lost in the Black Hole
Citation Text:
Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/node/41634/psn-pdf
January 31, 2013 - Disclosure of harmful medical errors in out-of-hospital
care.
January 31, 2013
Lu DW, Guenther E, Wesley AK, et al. Disclosure of harmful medical errors in out-of-hospital care. Ann
Emerg Med. 2013;61(2):215-21. doi:10.1016/j.annemergmed.2012.07.004.
https://psnet.ahrq.gov/issue/disclosure-harmful-medical-errors-o…