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  1. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/74277
    January 01, 2021 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Medication/Drug Errors Curated Library Primers Medication Administration Errors Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March, 12 2021 Medication administration errors are a persistent patient saf…

  2. An Easily Forgotten Tube | PSNet

    psnet.ahrq.gov/web-mm/easily-forgotten-tube
    June 01, 2016 - An Easily Forgotten Tube Citation Text: Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

  3. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
    May 01, 2015 - PowerPoint Presentation Spotlight Errors in Sepsis Management This presentation is based on the May 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF) Editor, AHRQ WebM&M: Rober…

  4. Patient Safety 101 | PSNet

    psnet.ahrq.gov/primer/patient-safety-101
    January 16, 2025 - Patient Safety 101 Citation Text: Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS D…

  5. Coming Up Short | PSNet

    psnet.ahrq.gov/web-mm/coming-short
    May 20, 2020 - Coming Up Short Citation Text: Hochberg Z'ev. Coming Up Short. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33713/psn-pdf
    June 01, 2011 - The Safety of Medical Devices June 1, 2011 Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/safety-medical-devices Perspective Edward Tenner is right. Technology does have reverberations, including unintended consequences, or "revenge effects."(1) While such dra…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49412/psn-pdf
    September 01, 2003 - Shake Well September 1, 2003 Flynn EA. Shake Well. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/shake-well The Case A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily serum drug levels consistently fell below the therapeutic range, which led the physi…

  8. Never Events | PSNet

    psnet.ahrq.gov/primer/never-events
    June 15, 2024 - Never Events Citation Text: Never Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50844/psn-pdf
    January 29, 2020 - Improving Patient Safety and Team Communication through Daily Huddles January 29, 2020 Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles Background Communicat…

  10. Update: Patient Engagement in Safety | PSNet

    psnet.ahrq.gov/perspective/update-patient-engagement-safety
    January 01, 2017 - Annual Perspective Update: Patient Engagement in Safety Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2018  View more articles from the same authors. Citation Text: Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. Rockvi…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60929/psn-pdf
    September 16, 2020 - Safer Together: A National Action Plan to Advance Patient Safety. September 16, 2020 Boston, MA: Institute for Healthcare Improvement: September 2020.   https://psnet.ahrq.gov/issue/national-action-plan-advance-patient-safety This National Action Plan developed by the National Steering Committee for Pati…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34715/psn-pdf
    February 18, 2011 - Continuous improvement as an ideal in health care. February 18, 2011 Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56. https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care Two approaches to improving quality in health care are illustrated in this artic…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73075/psn-pdf
    March 24, 2021 - Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges. March 24, 2021 ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(5):1-6. https://psnet.ahrq.gov/issue/analysis-transdermal-medication-patch-errors-uncovers-patchwork-safety- challenges Skin patches are a conveni…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846164/psn-pdf
    March 15, 2023 - Crowding in the Emergency Department: Challenges for the Care of Children. March 15, 2023 Gross TK, Lane NE, Timm NL, et al. Crowding in the Emergency Department: Challenges for the Care of Children. Pediatrics. 2023;151(3):e2022060971-e2022060972. doi:10.1542/peds.2022-060971. https://psnet.ahrq.gov/issue/crowdin…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42645/psn-pdf
    October 09, 2013 - Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative. October 9, 2013 Rockville, MD: Agency for Healthcare Research and Quality; July 2013. AHRQ Publication No. 13-0071- EF. https://psnet.ahrq.gov/issue/eliminating-cauti-interim-data-report-national-patient-safety-imperative This report pr…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44170/psn-pdf
    May 29, 2023 - Ambulatory Surgery Center Survey on Patient Safety Culture. May 29, 2023 Rockville, MD: Agency for Healthcare Research and Quality; October 2020. https://psnet.ahrq.gov/issue/ambulatory-surgery-center-survey-patient-safety-culture Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical ca…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72849/psn-pdf
    March 17, 2021 - There's no place like home--integrating a pharmacist into the hospital-in-home model. March 17, 2021 Emonds EE, Pietruszka BL, Hawley CE, et al. There’s no place like home—integrating a pharmacist into the hospital-in-home model. J Am Pharm Assoc (2003). 2021;61(3):e143-e151. doi:10.1016/j.japh.2021.01.003. https…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50554/psn-pdf
    October 16, 2019 - Adverse events in the operating room: definitions, prevalence, and characteristics. A systematic review. October 16, 2019 Jung JJ, Elfassy J, Jüni P, et al. Adverse Events in the Operating Room: Definitions, Prevalence, and Characteristics. A Systematic Review. World J Surg. 2019;43(10):2379-2392. doi:10.1007/s0026…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848383/psn-pdf
    May 03, 2023 - Burnout in Primary Care: Assessing and Addressing It in Your Practice. May 3, 2023 Gerteis J, Booker C, Brach C, et al. Rockville, MD:  Agency for Healthcare Research and Quality; February 2023. AHRQ Publication No. 23-0025. https://psnet.ahrq.gov/issue/burnout-primary-care-assessing-and-addressing-it-your-pr…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34873/psn-pdf
    February 18, 2011 - Nurse-staffing levels and the quality of care in hospitals. February 18, 2011 Needleman J, Buerhaus P, Mattke S, et al. Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346(22):1715-22. https://psnet.ahrq.gov/issue/nurse-staffing-levels-and-quality-care-hospitals The relationship betw…
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