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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - Medication Reconciliation Pitfalls
Citation Text:
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - The Dangerous Detour
Citation Text:
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/33811/psn-pdf
June 01, 2016 - Becoming a Certified Professional in Patient Safety—A
Pharmacist's Perspective
June 1, 2016
Khudeira Z. Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective. PSNet
[internet]. 2016.
https://psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
…
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psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
December 07, 2009 - SPOTLIGHT CASE
No News May Not Be Good News
Citation Text:
Moore CR. No News May Not Be Good News. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/49690/psn-pdf
September 01, 2013 - The Pains of Chronic Opioid Usage
September 1, 2013
Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
Case Objectives
Describe the appropriate initial assessment of patients with chronic non-cancer pain.
List the most comm…
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - U.S. Department of Veterans Affairs Medical Center,
Houston, TX, and Baylor College of Medicine Revised
Safer Diagnosis (Safer Dx) Instrument
January 26, 2022
https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-
college-medicine
Summary
The Revised Safer Dx Instr…
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - Anchoring Bias With Critical Implications
June 1, 2015
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
Case Objectives
Appreciate that diagnostic errors are common in primary and ambulatory care.
Define premature clo…
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psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
May 31, 2023 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
Citation Text:
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - SPOTLIGHT CASE
False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.
Citation Text:
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
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psnet.ahrq.gov/issue/impact-health-information-technology-detection-potential-adverse-drug-events-ordering-stage
June 25, 2008 - Study
Impact of health information technology on detection of potential adverse drug events at the ordering stage.
Citation Text:
Roberts LL, Ward MM, Brokel JM, et al. Impact of health information technology on detection of potential adverse drug events at the ordering stage. Am J Hea…
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psnet.ahrq.gov/issue/retrospective-evaluation-computerized-physician-order-entry-adaptation-prevent-prescribing
May 27, 2011 - Study
Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department.
Citation Text:
Sard BE, Walsh KE, Doros G, et al. Retrospective evaluation of a computerized physician order entry adaptation to prevent …
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psnet.ahrq.gov/issue/toward-constructive-change-after-making-medical-error-recovery-situations-error-theory
March 04, 2015 - Review
Toward constructive change after making a medical error: recovery from situations of error theory as a psychosocial model for clinician recovery.
Citation Text:
Harrison R, Johnson J, Mcmullan RD, et al. Toward constructive change after making a medical error: recovery from situat…
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psnet.ahrq.gov/issue/expanding-role-antimicrobial-stewardship-programs-hospitals-united-states-lessons-learned
March 04, 2015 - Study
The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons learned from a multisite qualitative study.
Citation Text:
Kapadia SN, Abramson EL, Carter EJ, et al. The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the Uni…
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psnet.ahrq.gov/issue/patient-perceptions-mistakes-ambulatory-care
July 29, 2015 - Study
Patient perceptions of mistakes in ambulatory care.
Citation Text:
Kistler CE, Walter LC, Mitchell M, et al. Patient perceptions of mistakes in ambulatory care. Arch Intern Med. 2010;170(16):1480-7. doi:10.1001/archinternmed.2010.288.
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DOI Google …
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psnet.ahrq.gov/issue/comprehensive-departmental-care-review-model-requirements-structure-and-flow
July 06, 2022 - Commentary
A comprehensive departmental care review model: requirements, structure, and flow.
Citation Text:
Nestler DM, Laack TA, Scanlan-Hanson L, et al. A comprehensive departmental care review model: requirements, structure, and flow. Jt Comm J Qual Patient Saf. 2021;47(8):503-509. d…
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psnet.ahrq.gov/issue/prospective-validation-classification-intraoperative-adverse-events-classintra-international
November 20, 2015 - Study
Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study.
Citation Text:
Dell-Kuster S, Gomes NV, Gawria L, et al. Prospective validation of classification of intraoperative adverse events (ClassIntra): internat…
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psnet.ahrq.gov/issue/patients-story-examination-patient-reported-safety-incidents-general-practice
November 03, 2021 - Study
The patient's "story": an examination of patient-reported safety incidents in general practice.
Citation Text:
Madden C, Lydon S, Murphy AW, et al. The patient’s “story”: an examination of patient-reported safety incidents in general practice. Fam Pract. 2022;39(6):1095-1102. doi:1…
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psnet.ahrq.gov/issue/differences-reasons-alert-overrides-contraindicated-co-prescriptions-admitting-department
January 23, 2017 - Study
Differences of reasons for alert overrides on contraindicated co-prescriptions by admitting department.
Citation Text:
Ahn EK, Cho S-Y, Shin D, et al. Differences of Reasons for Alert Overrides on Contraindicated Co-prescriptions by Admitting Department. Healthc Inform Res. 2014;20…
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psnet.ahrq.gov/issue/helping-healthcare-teams-save-lives-during-covid-19-insights-and-countermeasures-team-science
June 24, 2020 - Commentary
Emerging Classic
Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science.
Citation Text:
Traylor AM. Helping healthcare teams save lives during COVID-19: insights and countermeasures from team science. Am Ps…
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psnet.ahrq.gov/issue/mixed-methods-systematic-review-interventions-address-incivility-nursing
December 02, 2020 - Review
A mixed-methods systematic review of interventions to address incivility in nursing.
Citation Text:
Olsen JM, Aschenbrenner A, Merkel R, et al. A mixed-methods systematic review of interventions to address incivility in nursing. J Nurs Educ. 2020;59(6):319-326. doi:10.3928/0148483…