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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - Part of the response of physicians to technology and decision support systems is predicated by which
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - Related Resources From the Same Author(s)
Evaluating implementation of a rapid response
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psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
January 01, 2015 - Look at what's going on in General Motors in response to ignition switch problems that have led to deaths
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psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
March 10, 2021 - influence whether a survey is the right tool or if the timing of implementation will get an effective response
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psnet.ahrq.gov/perspective/application-safety-ii-principles
August 28, 2024 - recurrent event that we've heard about, or sometimes it's problematic or high-risk processes, like our response
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psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
January 01, 2015 - Look at what's going on in General Motors in response to ignition switch problems that have led to deaths
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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - recurrent event that we've heard about, or sometimes it's problematic or high-risk processes, like our response
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psnet.ahrq.gov/curated-library/medicationdrug-errorsqqrysd
March 12, 2021 - Breadcrumb
My PSNet Account
My Libraries
Subscribed
Medication/Drug Errors'qQRysd<'">AVbUfV
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Last Updated: August 22, 2022
Created By: Dr. Yan Xiao, AHRQ TE…
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psnet.ahrq.gov/issue/optimizing-medication-reconciliation-and-transitions-care-insights-pharmacist-and-pharmacy
July 25, 2023 - International Meeting/Conference
Optimizing Medication Reconciliation and Transitions of Care: Insights from a Pharmacist and Pharmacy Technician.
Citation Text:
Health Quality Institute. July 12, 2023, 2:00-3:00 PM (eastern).
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psnet.ahrq.gov/training
October 06, 2007 - Training Catalog
The AHRQ PSNet Training Catalog is an easy to use resource for healthcare professionals across all settings of care and specialties looking for education opportunities to further their knowledge of patient safety practices and principles. So…
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psnet.ahrq.gov/issue/judy-smetzer-just-culture-champion-scholarships
April 18, 2012 - Press Release/Announcement
Judy Smetzer Just Culture Champion Scholarships.
Citation Text:
Institute for Safe Medication Practices.
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - Medication Overdose
Citation Text:
Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat
Hyponatremia
January 29, 2020
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet].
2020.
https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
The Case
A 54-year-old man was brought t…
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
September 01, 2006 - Spotlight Case September 2006
Spotlight Case September 2006
Triple Handoff
Source and Credits
This presentation is based on the September 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Arpana Vidyarthi, MD, UCSF Sc…
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psnet.ahrq.gov/node/49396/psn-pdf
April 01, 2003 - The 2-Week Itch
April 1, 2003
Cohen MR. The 2-Week Itch. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/2-week-itch
The Case
A 40-year-old woman with bipolar disorder (on trazodone) came to her primary care physician with new
urticaria. She received a handwritten prescription for Zyrtec and Atarax.
The ha…
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psnet.ahrq.gov/node/49599/psn-pdf
February 23, 2010 - Defensive Medicine: "Glowing" with Pain
February 1, 2010
Sethi MK. Defensive Medicine: "Glowing" with Pain. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
The Case
A 31-year-old man presented to the emergency department (ED) complaining of abdominal pain and
vomiting. The…
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psnet.ahrq.gov/node/49683/psn-pdf
April 01, 2013 - Acute Care Admission of the Behavioral Health Patient
April 1, 2013
Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
The Case
A 25-year-old man presented to the emergency department (E…
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psnet.ahrq.gov/node/49391/psn-pdf
February 01, 2003 - When "Psychiatric" Symptoms Are Not
February 1, 2003
Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
The Case
A 70-year-old man without documented past psychiatric history was placed on an involuntary hold as a
danger to oth…
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psnet.ahrq.gov/node/49575/psn-pdf
November 01, 2008 - Sick and Pregnant
November 1, 2008
El-Ibiary S. Sick and Pregnant. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/sick-and-pregnant
The Case
A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty
breathing. The patient informed the staff that she was 17 weeks pre…