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  1. Psn-Pdf (pdf file)

    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…
  2. 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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. 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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. 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…
  20. Psn-Pdf (pdf file)

    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…

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