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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - SPOTLIGHT CASE
Beeline to Spine
Citation Text:
Smetana GW. Beeline to Spine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - Ebola: Are We Ready?
Citation Text:
Barsuk JH, Barnard C. Ebola: Are We Ready?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - Never Events
September 15, 2024
Never Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/never-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Backg…
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psnet.ahrq.gov/node/42707/psn-pdf
September 03, 2024 - Quality Institute Toolkits.
September 3, 2024
AAAHC Quality Institute. Deerfield, IL: Accreditation Association for Ambulatory Health Care.
https://psnet.ahrq.gov/issue/quality-institute-toolkits
This collection of toolkits provides resources to support safety in ambulatory care and includes information
about alle…
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psnet.ahrq.gov/node/38522/psn-pdf
May 08, 2018 - Beware of basal opioid infusions with PCA therapy.
May 8, 2018
ISMP Medication Safety Alert! Acute Care Edition. March 12, 2009;14:1-3.
https://psnet.ahrq.gov/issue/beware-basal-opioid-infusions-pca-therapy
This article provides screening, dosing, and monitoring recommendations for using basal opioid infusions
and…
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psnet.ahrq.gov/node/34851/psn-pdf
December 23, 2016 - Preventing, and managing the impact of, anesthesia
awareness.
December 23, 2016
Preventing, and managing the impact of, anesthesia awareness. Sentinel Event Alert. 2004;32:1-3.
https://psnet.ahrq.gov/issue/preventing-and-managing-impact-anesthesia-awareness
This alert provides recommendations for minimizing the ri…
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psnet.ahrq.gov/node/40378/psn-pdf
June 01, 2024 - Organisation Patient Safety Incident Reports.
May 18, 2018
National Patient Safety Agency
https://psnet.ahrq.gov/issue/organisation-patient-safety-incident-reports
This Web site provides data on safety incidents from the United Kingdom in the form of workbooks sorted
by either organization or region. In June 2024,…
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psnet.ahrq.gov/node/34574/psn-pdf
March 07, 2005 - Safe Handling of Hazardous Drugs.
March 7, 2005
Polovich M; Blecher CS; Glynn-Tucker EM; McDiarmid M; Newton SA
https://psnet.ahrq.gov/issue/safe-handling-hazardous-drugs
This guideline provides recommendations to enhance the safe delivery of high-risk medications. Topics
include assessing occupational exposure ri…
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psnet.ahrq.gov/node/42490/psn-pdf
August 14, 2013 - Sentinel Event Program.
August 14, 2013
Division of Licensing and Regulatory Services; Maine Department of Health and Human Services.
https://psnet.ahrq.gov/issue/sentinel-event-program
This Web site provides information about Maine's statewide incident reporting initiative and includes annual
sentinel event repor…
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psnet.ahrq.gov/node/42242/psn-pdf
September 06, 2018 - World Sepsis Day.
September 6, 2018
Global Sepsis Alliance.
https://psnet.ahrq.gov/issue/world-sepsis-day
This website provides resources to raise awareness of sepsis, including information about its increasing
incidence and causes for its delayed diagnosis. World Sepsis Day occurs yearly on September 13th.
https…
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psnet.ahrq.gov/node/35346/psn-pdf
September 21, 2005 - Guide to Healthcare Quality: How to Know It When You
See It.
September 21, 2005
Rockville, MD: Agency for Healthcare Research and Quality; 2005.
https://psnet.ahrq.gov/issue/guide-healthcare-quality-how-know-it-when-you-see-it
Part of the Agency for Healthcare Research and Quality's (AHRQ) consumer education campa…
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psnet.ahrq.gov/node/35517/psn-pdf
November 17, 2016 - Joint Commission Journal on Quality and Patient Safety.
November 17, 2016
Baker D, ed. Oakbrook Terrace, IL: Joint Commission. ISSN: 1553-7250.
https://psnet.ahrq.gov/issue/joint-commission-journal-quality-and-patient-safety
This monthly, peer-reviewed journal provides both empirical studies and practical instructi…
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psnet.ahrq.gov/node/39455/psn-pdf
May 28, 2014 - Pediatric Patient Safety in the Emergency Department.
May 28, 2014
Krug SE, ed. Oakbrook Terrace, IL: Joint Commission Resources and the American Academy of
Pediatrics; 2010. ISBN: 9781599402123.
https://psnet.ahrq.gov/issue/pediatric-patient-safety-emergency-department
This book presents tools, examples, strategi…
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psnet.ahrq.gov/node/35330/psn-pdf
April 04, 2021 - "Talk About Your Medicines" Month.
April 4, 2021
BeMedWise Program at NeedyMeds, Gloucester, MA.
https://psnet.ahrq.gov/issue/talk-about-your-medicines-month
This Web site provides information and tools that support an educational campaign to encourage high-
quality communication about medication use. The annual o…
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psnet.ahrq.gov/node/35867/psn-pdf
April 29, 2018 - IV potassium given epidurally: getting to the "route" of
the problem.
April 29, 2018
ISMP Medication Safety Alert! Acute care edition. April 6, 2006.
https://psnet.ahrq.gov/issue/iv-potassium-given-epidurally-getting-route-problem
This article outlines systems failures that can contribute to the inadvertent misadm…
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psnet.ahrq.gov/node/36353/psn-pdf
October 27, 2010 - Ways to avert potential patient care disasters.
October 27, 2010
Spath P. Ways to avert potential patient care disasters. Hospital peer review. 2006;31(9):128-30.
https://psnet.ahrq.gov/issue/ways-avert-potential-patient-care-disasters
This article discusses clinician failure to recognize patient deterioration and …
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psnet.ahrq.gov/node/43337/psn-pdf
July 09, 2014 - My Medicines.
July 9, 2014
Silver Spring, MD: US Food and Drug Administration. Office of Women's Health and National Association
of Chain Drug Stores.
https://psnet.ahrq.gov/issue/my-medicines
This toolkit offers tips for patients to prevent adverse drug events and provides a way to record important
medication in…
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psnet.ahrq.gov/node/42389/psn-pdf
September 02, 2016 - Report on the ISPE Drug Shortages Survey.
September 2, 2016
Tampa, FL: International Society for Pharmaceutical Engineering; June 2013.
https://psnet.ahrq.gov/issue/report-ispe-drug-shortages-survey
This worldwide survey determined root causes and underlying issues contributing to drug shortages and
provides recom…
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psnet.ahrq.gov/node/36995/psn-pdf
September 14, 2011 - Adverse drug events in the elderly.
September 14, 2011
Cresswell KM, Fernando B, McKinstry B, et al. Adverse drug events in the elderly. Br Med Bull. 2007;83(1).
doi:10.1093/bmb/ldm016.
https://psnet.ahrq.gov/issue/adverse-drug-events-elderly
The authors discuss drug-related adverse events in the elderly and provi…