-
psnet.ahrq.gov/node/34763/psn-pdf
March 07, 2005 - The Limits of Safety: Organizations, Accidents and
Nuclear Weapons.
March 7, 2005
Sagan SD. Princeton NJ: Princeton University Press; 1993. ISBN: 9780691032214.
https://psnet.ahrq.gov/issue/limits-safety-organizations-accidents-and-nuclear-weapons
Two competing paradigms dominate the study of the hazards associate…
-
psnet.ahrq.gov/node/44189/psn-pdf
September 09, 2015 - Variation in printed handoff documents: results and
recommendations from a multicenter needs assessment.
September 9, 2015
Rosenbluth G, Bale JF, Starmer AJ, et al. Variation in printed handoff documents: Results and
recommendations from a multicenter needs assessment. J Hosp Med. 2015;10(8):517-24.
doi:10.1002/jh…
-
psnet.ahrq.gov/node/72546/psn-pdf
December 09, 2020 - Learning from incident reporting? Analysis of incidents
resulting in patient injuries in a web-based system in
Swedish health care.
December 9, 2020
Ahlberg E-L, Elfström J, Borgstedt MR, et al. Learning from incident reporting? Analysis of incidents
resulting in patient injuries in a web-based system in Swedish h…
-
psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
-
psnet.ahrq.gov/issue/emergency-nursing-and-medical-error-survey-two-states
January 25, 2010 - December 1, 2011
Are temporary staff associated with more severe emergency department
-
psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - Antiseizure Medication Disorder
May 1, 2007
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
Case Objectives
Appreciate the challenges of safe use of antiepileptic medications.
Identify phenytoin toxicity.
Understand the pharmaco…
-
psnet.ahrq.gov/node/33566/psn-pdf
September 15, 2024 - Teamwork Training
September 15, 2024
Teamwork Training. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/teamwork-training
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed …
-
psnet.ahrq.gov/issue/ismp-quarterwatch-reports
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
-
psnet.ahrq.gov/issue/2017-ismp-medication-safety-self-assessment-communityambulatory-pharmacy
June 07, 2017 - May 11, 2017
Severe hyperglycemia in patients incorrectly using insulin pens at home.
-
psnet.ahrq.gov/issue/patient-safety-24
December 01, 2011 - July 8, 2013
Are temporary staff associated with more severe emergency department medication
-
psnet.ahrq.gov/issue/nursing-care-quality-nqf
September 06, 2011 - July 8, 2009
Antecedents of severe and nonsevere medication errors.
-
psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - Validation of test performance and clinical time zero for an electronic health record embedded severe
-
psnet.ahrq.gov/node/49811/psn-pdf
November 01, 2017 - worsening respiratory status, liver abnormalities, and colonic pseudo-obstruction were all
consistent with severe … These are rare but life-threatening conditions that result from either decompensated
thyrotoxicosis or severe … Effects Score
Absent 0
Mild (agitation) 10
Moderate (delirium, psychosis, extreme lethargy) 20
Severe … 25
Congestive Heart Failure Score
Absent 0
Mild (pedal edema) 5
Moderate (bibasilar rales) 10
Severe
-
psnet.ahrq.gov/node/46660/psn-pdf
October 18, 2018 - Using a network organisational architecture to support
the development of Learning Healthcare Systems.
October 18, 2018
Britto MT, Fuller SC, Kaplan HC, et al. Using a network organisational architecture to support the
development of Learning Healthcare Systems. BMJ Qual Saf. 2018;27(11). doi:10.1136/bmjqs-2017-
0…
-
psnet.ahrq.gov/node/42230/psn-pdf
October 06, 2016 - Using Lean to improve medication administration safety:
in search of the "perfect dose."
October 6, 2016
Ching JM, Long C, Williams BL, et al. Using lean to improve medication administration safety: in search of
the "perfect dose". Jt Comm J Qual Patient Saf. 2013;39(5):195-204.
https://psnet.ahrq.gov/issue/using-…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - advanced care discussions
Case: Code Status Confusion
A 60-year-old woman with a history of severe … preferences in scenarios with uncertain outcomes
i.e., successful cardiac resuscitation with resultant severe
-
psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
February 06, 2019 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
-
psnet.ahrq.gov/issue/ismp-long-term-care-advise-err
June 07, 2017 - June 13, 2018
Severe hyperglycemia in patients incorrectly using insulin pens at home
-
psnet.ahrq.gov/issue/clinical-issues-series
July 05, 2006 - 2006
National Partnership for Maternal Safety: consensus bundle on support after a severe
-
psnet.ahrq.gov/issue/fatal-gas-line-mix-how-avoid-making-gastly-mistake
April 29, 2018 - September 12, 2016
ALERT: reports of severe harm after intravenous administration of