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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - Eptifibatide Epilogue
April 1, 2009
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue
The Case
A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute
coronary syndrome. Serial testing for mark…
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple
Health System Vulnerabilities
May 26, 2021
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health
System Vulnerabilities. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - New Patient Mistakenly Checked in as Another
Citation Text:
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. 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/node/60609/psn-pdf
June 24, 2020 - When the Indications for Drug Administration Blur
June 24, 2020
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accre…
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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - The Forgotten Radiographic Read
Citation Text:
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/hiding-plain-sight
April 24, 2019 - Hiding in Plain Sight
Citation Text:
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/node/49605/psn-pdf
June 01, 2010 - Acute Respiratory Arrest in Pregnancy
June 1, 2010
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
The Case
A 35-year-old woman was 38 weeks pregnant with twins (G3P2). When she developed acute onset of
shortness of breath an…
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - this one, many operating teams prefer endotracheal
intubation to procedural sedation alone because it reduces
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psnet.ahrq.gov/issue/association-between-waiting-times-and-short-term-mortality-and-hospital-admission-after
May 19, 2018 - Study
Classic
Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada.
Citation Text:
Guttmann A, Schull MJ, Vermeulen MJ, et al. Associatio…
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psnet.ahrq.gov/issue/unexpected-death-within-72-hours-emergency-department-visit-were-those-deaths-preventable
July 08, 2020 - Study
Unexpected death within 72 hours of emergency department visit: were those deaths preventable?
Citation Text:
Goulet H, Guerand V, Bloom B, et al. Unexpected death within 72 hours of emergency department visit: were those deaths preventable? Crit Care. 2015;19(1):154. doi:10.1186/s…
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psnet.ahrq.gov/issue/evaluating-mobile-application-improving-clinical-laboratory-test-ordering-and-diagnosis
August 07, 2019 - Study
Evaluating a mobile application for improving clinical laboratory test ordering and diagnosis.
Citation Text:
Meyer AND, Thompson PJ, Khanna A, et al. Evaluating a mobile application for improving clinical laboratory test ordering and diagnosis. J Am Med Inform Assoc. 2018;25(7):84…
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psnet.ahrq.gov/issue/prevalence-severity-and-nature-preventable-patient-harm-across-medical-care-settings
February 17, 2021 - Study
Classic
Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.
Citation Text:
Panagioti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across…
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psnet.ahrq.gov/issue/consumer-involvement-design-and-development-medication-safety-interventions-or-services
August 30, 2023 - Review
Consumer involvement in the design and development of medication safety interventions or services in primary care: a scoping review.
Citation Text:
DelDot M, Lau E, Rayner N, et al. Consumer involvement in the design and development of medication safety interventions or services i…
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psnet.ahrq.gov/issue/early-experience-peer-advocate-program-using-quality-improvement-optimize-behavioral-and
September 23, 2020 - Study
Early experience of peer advocate program: using quality improvement to optimize behavioral and communication disconnect in the operating room.
Citation Text:
Eckhouse SR, Huston M, Smith ER, et al. Early experience of peer advocate program: using quality improvement to optimize be…
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psnet.ahrq.gov/issue/making-health-care-safer-critical-analysis-patient-safety-practices
July 27, 2018 - Book/Report
Making Health Care Safer: A Critical Analysis of Patient Safety Practices.
Citation Text:
Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Shojania KG, Duncan BW, McDonald KM, et al, eds. Rockville, MD: Agency for Healthcare Research and Quality; J…
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psnet.ahrq.gov/issue/association-interruptions-increased-risk-and-severity-medication-administration-errors
August 26, 2020 - Study
Classic
Association of interruptions with an increased risk and severity of medication administration errors.
Citation Text:
Westbrook JI, Woods A, Rob MI, et al. Association of interruptions with an increased risk and severity of medication administration…
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psnet.ahrq.gov/issue/defining-identifying-and-addressing-problematic-polypharmacy-within-multimorbidity-primary
July 22, 2015 - Review
Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review.
Citation Text:
Tsang JY, Sperrin M, Blakeman T, et al. Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scop…
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psnet.ahrq.gov/issue/methodological-variations-and-their-effects-reported-medication-administration-error-rates
January 15, 2025 - Review
Methodological variations and their effects on reported medication administration error rates.
Citation Text:
McLeod MC, Barber N, Franklin BD. Methodological variations and their effects on reported medication administration error rates. BMJ Qual Saf. 2013;22(4):278-89. doi:10.…
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psnet.ahrq.gov/issue/systematic-review-teamwork-intensive-care-unit-what-do-we-know-about-teamwork-team-tasks-and
January 23, 2019 - Review
A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies?
Citation Text:
Dietz AS, Pronovost P, Mendez-Tellez PA, et al. A systematic review of teamwork in the intensive care unit: what do we know about team…
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psnet.ahrq.gov/issue/older-patients-engagement-hospital-medication-safety-behaviours
November 17, 2021 - Study
Older patients' engagement in hospital medication safety behaviours.
Citation Text:
Tobiano G, Chaboyer W, Dornan G, et al. Older patients’ engagement in hospital medication safety behaviours. Aging Clin Exp Res. 2021;33(12):3353-3361. doi:10.1007/s40520-021-01866-3.
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