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  1. psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
    September 26, 2012 - Amended Lab Results: Communication Slip Citation Text: Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  2. psnet.ahrq.gov/web-mm/urine-tough-position
    January 01, 2009 - Urine a Tough Position Citation Text: Gandhi TK. Urine a Tough Position. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33825/psn-pdf
    January 01, 2017 - Rethinking Root Cause Analysis January 1, 2016 Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis Annual Perspective 2016 Introduction Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
  4. psnet.ahrq.gov/web-mm/shake-well
    September 01, 2006 - Shake Well Citation Text: Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downloa…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33834/psn-pdf
    May 22, 2017 - Opioid Overdose as a Patient Safety Problem May 22, 2017 Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem Perspective Opioids serve a valuable role in the treatment of acute pain and pain associat…
  6. psnet.ahrq.gov/web-mm/misread-label
    August 28, 2024 - Misread Label Citation Text: Franklin BD. Misread Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837785/psn-pdf
    August 05, 2022 - Emergence of Application-based Healthcare August 5, 2022 Marvel FA, Dowell P, Mossburg SE. Emergence of Application-based Healthcare. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/emergence-application-based-healthcare Introduction The demand for digital healthcare, including both telemedicine and hea…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49542/psn-pdf
    August 21, 2007 - Copy and Paste August 21, 2007 Hersh WR. Copy and Paste. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/copy-and-paste The Case A 77-year-old woman was admitted to a teaching hospital with diarrhea and dehydration after completing her fifth cycle of chemotherapy for ovarian cancer. Her only relevant past m…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33621/psn-pdf
    November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience November 1, 2005 Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience Perspective Health care organizations throughout the world have ide…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60168/psn-pdf
    March 25, 2020 - Right Electrocardiogram, Wrong Patient March 25, 2020 Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient The Cases Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73412/psn-pdf
    August 01, 2022 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV) June 30, 2021 https://psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and- disclosure Summary The Behavioral Health Vital Signs (BHVS) screener i…
  12. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.149_slideshow.ppt
    May 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case May 2007 Antiseizure Medication Disorder Source and Credits This presentation is based on the May 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Brian K. Alldredge, Pharm…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60547/psn-pdf
    May 28, 2020 - The Role of the FDA in Ensuring Device Safety May 28, 2020 Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety Introduction The Food and Drug Administration (FDA) plays a critical role in ensuring the …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49814/psn-pdf
    December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation Mishap December 1, 2017 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap The Case A 63-year-old man with a history of coronary…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33640/psn-pdf
    September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? September 1, 2006 Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33698/psn-pdf
    August 01, 2010 - In Conversation with...Richard P. Shannon, MD August 1, 2010 In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the University of Pe…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49659/psn-pdf
    July 01, 2012 - Sloppy and Paste July 1, 2012 Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/sloppy-and-paste The Case A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new onset chest pain. The ED physician reviewed the patient's electronic me…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49803/psn-pdf
    January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3 August 1, 2017 Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3 The Case A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the app…
  19. psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
    December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005  View more articles from the same authors. Citation Text: Conway JB, Weingart SN. Organizational Change…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33727/psn-pdf
    March 01, 2012 - Can Research Help Us Improve the Medical Liability System? March 1, 2012 Kachalia A. Can Research Help Us Improve the Medical Liability System? PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system Perspective The United States medical malpractice liabili…

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