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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - Primary Care and Patient Safety: Opportunities at the
Interface
September 28, 2022
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
Editor’s Not…
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psnet.ahrq.gov/issue/malnourishment-epidemic-plagues-hospitals-really
June 04, 2014 - , 2014
Do variations in hospital mortality patterns after weekend admission reflect reduced
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psnet.ahrq.gov/node/42063/psn-pdf
January 06, 2018 - These practices, if implemented, should result in reduced harm from a wide range of
safety threats,
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psnet.ahrq.gov/issue/pregnancy-related-deaths-saving-womens-lives-during-and-after-delivery
September 07, 2016 - November 16, 2022
CDC guideline for opioid prescribing associated with reduced dispensing
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psnet.ahrq.gov/web-mm/transition-nowhere
March 21, 2009 - Transition to Nowhere
Citation Text:
Farrell TW. Transition to Nowhere. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…
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psnet.ahrq.gov/web-mm/troubling-amine
September 01, 2003 - A Troubling Amine
Citation Text:
Flynn EA. A Troubling Amine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/node/49731/psn-pdf
April 01, 2015 - Fire in the Hole!—An OR Fire
April 1, 2015
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fire-hole-or-fire
The Case
A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection
for a biopsy-proven adenocarcinom…
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psnet.ahrq.gov/node/33772/psn-pdf
September 01, 2014 - In Conversation With… Rosemary Gibson, MSc
September 1, 2014
In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
Editor's note: Rosemary Gibson, MSc, is Senior Advisor to The Hastings Center and an editor for JAMA
Internal Medicin…
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psnet.ahrq.gov/node/49637/psn-pdf
October 01, 2011 - The Dropped "No"
October 1, 2011
Johnson AJ. The Dropped "No". PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropped-no
The Case
A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in
his legs. Because the leg swelling was somewhat more pronounced in his…
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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…
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psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
October 01, 2003 - Hospital Admission Due to High-Dose Methotrexate Drug Interaction
Citation Text:
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - Perhaps better communication across settings during points of transition could have reduced the resident's … Patient Safety Goals for Long Term Care include accurate resident identification, safe medication use, reduced … health care-associated infections, reconciled medications, reduced harm from falls, and reduced health
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psnet.ahrq.gov/issue/ethical-challenges-child-abuse-what-harm-misdiagnosis
September 01, 2021 - Commentary
Ethical challenges in child abuse: what is the harm of a misdiagnosis?
Citation Text:
Brown SD. Ethical challenges in child abuse: what is the harm of a misdiagnosis? Pediatr Radiol. 2021;51(6):1070-1075. doi:10.1007/s00247-020-04845-4.
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DOI …
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psnet.ahrq.gov/issue/telediagnosis-acute-care-implications-quality-and-safety-diagnosis
January 11, 2017 - Book/Report
Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis.
Citation Text:
Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis. Smith KM, Hunte HE, Graber ML. Rockville MD: Agency for Healthcare Research and Quality; Augu…
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psnet.ahrq.gov/issue/diagnostic-difficulty-and-error-primary-care-systematic-review
April 07, 2021 - Review
Diagnostic difficulty and error in primary care—a systematic review.
Citation Text:
Kostopoulou O, Delaney B, Munro CW. Diagnostic difficulty and error in primary care--a systematic review. Fam Pract. 2008;25(6):400-413. doi:10.1093/fampra/cmn071.
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…
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psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defining-clinical-reasoning
June 26, 2019 - Commentary
Emerging Classic
Drawing boundaries: the difficulty in defining clinical reasoning.
Citation Text:
Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning. Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0…
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psnet.ahrq.gov/issue/technical-mistakes-during-acquisition-electrocardiogram
March 09, 2022 - Review
Technical mistakes during the acquisition of the electrocardiogram.
Citation Text:
García-Niebla J, Llontop-García P, Valle-Racero JI, et al. Technical mistakes during the acquisition of the electrocardiogram. Ann Noninvasive Electrocardiol. 2009;14(4):389-403. doi:10.1111/j.154…
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psnet.ahrq.gov/issue/advancement-toward-high-reliability-healthcare-awards
June 08, 2011 - January 21, 2009
Teamwork is associated with reduced hospital staff burnout at military
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psnet.ahrq.gov/issue/fatal-drug-mix-exposes-hospital-flaws
March 02, 2016 - July 10, 2018
Teamwork is associated with reduced hospital staff burnout at military