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psnet.ahrq.gov/node/49755/psn-pdf
February 01, 2016 - Good Night's Sleep Gone Wrong
February 1, 2016
Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
The Case
A 64-year-old woman came to the emergency department complaining of cough and shortness of breath,
along with an…
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psnet.ahrq.gov/node/49742/psn-pdf
September 01, 2015 - A Fumbled Handoff to Inpatient Rehab
September 1, 2015
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
The Case
An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…
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psnet.ahrq.gov/node/49515/psn-pdf
July 01, 2006 - Over Not So Easy
July 1, 2006
Cucina R. Over Not So Easy. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/over-not-so-easy
The Case
A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On
admission, she reported allergies to a number of medications as well as a …
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psnet.ahrq.gov/node/49695/psn-pdf
October 01, 2013 - Finding Fault With the Default Alert
October 1, 2013
Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/finding-fault-default-alert
The Case
A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital
after experiencing …
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psnet.ahrq.gov/web-mm/mark-my-tooth
June 01, 2014 - Mark My Tooth
Citation Text:
Smith RA. Mark My Tooth. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
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psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety
Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN | September 1, 2008
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Rothschild JM, Keohane C. The Role of Bar Coding and Sm…
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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - In Conversation with...Geri Amori, PhD
December 1, 2010
Also Read an Essay
Citation Text:
In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010.In Conversation with...Geri Amori, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/845361/psn-pdf
March 29, 2023 - A standardized marking procedure for ENT operations to
prevent wrong-site surgery: development, establishment
and subsequent evaluation among patients and medical
personnel.
March 29, 2023
Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT operations to
prevent wrong-site sur…
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psnet.ahrq.gov/node/74050/psn-pdf
November 10, 2021 - Health disparities: impact of health disparities and
treatment decision-making biases on cancer adverse
effects among black cancer survivors.
November 10, 2021
Vo J, Gillman A, Mitchell K, et al. Health disparities: impact of health disparities and treatment decision-
making biases on cancer adverse effects among …
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psnet.ahrq.gov/node/39212/psn-pdf
March 04, 2011 - The impact of computerized provider order entry on
medication errors in a multispecialty group practice.
March 4, 2011
Devine EB, Hansen RN, Wilson-Norton JL, et al. The impact of computerized provider order entry on
medication errors in a multispecialty group practice. J Am Med Inform Assoc. 2010;17(1):78-84.
doi…
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psnet.ahrq.gov/node/45491/psn-pdf
May 09, 2017 - A systematic review of the types and causes of
prescribing errors generated from using computerized
provider order entry systems in primary and secondary
care.
May 9, 2017
Brown CL, Mulcaster HL, Triffitt KL, et al. A systematic review of the types and causes of prescribing errors
generated from using computerize…
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psnet.ahrq.gov/node/40586/psn-pdf
March 21, 2017 - Adopting real-time surveillance dashboards as a
component of an enterprisewide medication safety
strategy.
March 21, 2017
Waitman LR, Phillips IE, McCoy AB, et al. Adopting real-time surveillance dashboards as a component of
an enterprisewide medication safety strategy. Jt Comm J Qual Patient Saf. 2011;37(7):326-3…
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psnet.ahrq.gov/node/40656/psn-pdf
October 16, 2012 - Defining health information technology–related errors:
new developments since To Err Is Human.
October 16, 2012
Sittig DF, Singh H. Defining health information technology-related errors: new developments since to err is
human. Arch Intern Med. 2011;171(14):1281-4. doi:10.1001/archinternmed.2011.327.
https://psnet.…
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psnet.ahrq.gov/node/43956/psn-pdf
January 01, 2016 - Monitoring the harm associated with use of
anticoagulants in pediatric populations through trigger-
based automated adverse-event detection.
June 21, 2015
Patregnani JT, Spaeder MC, Lemon V, et al. Monitoring the harm associated with use of anticoagulants in
pediatric populations through trigger-based automated ad…
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psnet.ahrq.gov/node/40074/psn-pdf
July 03, 2014 - Evaluation of consistency in dosing directions and
measuring devices for pediatric nonprescription liquid
medications.
July 3, 2014
Yin S, Wolf MS, Dreyer BP, et al. Evaluation of consistency in dosing directions and measuring devices for
pediatric nonprescription liquid medications. JAMA. 2010;304(23):2595-602. d…
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psnet.ahrq.gov/node/42039/psn-pdf
December 31, 2014 - Enhancing patient safety and quality of care by improving
the usability of electronic health record systems:
recommendations from AMIA.
December 31, 2014
Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the
usability of electronic health record systems: recommen…
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psnet.ahrq.gov/node/47266/psn-pdf
August 08, 2018 - Outpatient opioid prescriptions for children and opioid-
related adverse events.
August 8, 2018
Chung CP, Callahan T, Cooper WO, et al. Outpatient Opioid Prescriptions for Children and Opioid-Related
Adverse Events. Pediatrics. 2018;142(2):e20172156. doi:10.1542/peds.2017-2156.
https://psnet.ahrq.gov/issue/outpati…
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psnet.ahrq.gov/node/47333/psn-pdf
October 10, 2018 - Changing dynamics of the drug overdose epidemic in the
United States from 1979 through 2016.
October 10, 2018
Jalal H, Buchanich JM, Roberts MS, et al. Changing dynamics of the drug overdose epidemic in the United
States from 1979 through 2016. Science (1979). 2018;361(6408). doi:10.1126/science.aau1184.
https://p…
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psnet.ahrq.gov/node/45385/psn-pdf
January 03, 2017 - Viewing prevention of catheter-associated urinary tract
infection as a system: using systems engineering and
human factors engineering in a quality improvement
project in an academic medical center.
January 3, 2017
Rhee C, Phelps E, Meyer B, et al. Viewing Prevention of Catheter-Associated Urinary Tract Infection …
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psnet.ahrq.gov/node/39045/psn-pdf
April 04, 2011 - Risks of complications by attending physicians after
performing nighttime procedures.
April 4, 2011
Rothschild JM. Risks of Complications by Attending Physicians After Performing Nighttime Procedures.
JAMA. 2009;302(14):1565-1572. doi:10.1001/jama.2009.1423.
https://psnet.ahrq.gov/issue/risks-complications-attendi…