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psnet.ahrq.gov/node/60825/psn-pdf
August 19, 2020 - Effect of delays in the 2-week-wait cancer referral
pathway during the COVID-19 pandemic on cancer
survival in the UK: a modelling study.
August 19, 2020
Sud A, Torr B, Jones ME, et al. Effect of delays in the 2-week-wait cancer referral pathway during the
COVID-19 pandemic on cancer survival in the UK: a modellin…
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psnet.ahrq.gov/issue/computerized-order-entry-systems-may-miss-medication-errors
July 28, 2010 - Newspaper/Magazine Article
Published July 28, 2010
Computerized order entry systems may miss medication errors.
Dolan PL.
Topics
Approach to Improving Safety
Computerized Adverse Event Detection
Computerized Prov…
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psnet.ahrq.gov/issue/complaints-about-acute-trusts-2013-14-and-q1-and-q2-2014-15
February 18, 2009 - Government Resource
December 17, 2014
Complaints About Acute Trusts 2013–14 and Q1 and Q2 2014–15.
Citation Text:
Parliamentary and Health Service Ombudsman.
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psnet.ahrq.gov/node/40993/psn-pdf
December 14, 2011 - Anticoagulation-associated adverse drug events.
December 14, 2011
Piazza G, Nguyen TN, Cios D, et al. Anticoagulation-associated Adverse Drug Events. Am J Med.
2011;124(12). doi:10.1016/j.amjmed.2011.06.009.
https://psnet.ahrq.gov/issue/anticoagulation-associated-adverse-drug-events
Warfarin and other anticoagulan…
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psnet.ahrq.gov/node/45575/psn-pdf
November 09, 2016 - Developing a high value care programme from the bottom
up: a programme of faculty-resident improvement
projects targeting harmful or unnecessary care.
November 9, 2016
Stinnett-Donnelly JM, Stevens PG, Hood VL. Developing a high value care programme from the bottom up:
a programme of faculty-resident improvement p…
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psnet.ahrq.gov/node/39800/psn-pdf
January 19, 2011 - Medication errors in paediatric outpatients.
January 19, 2011
Kaushal R, Goldmann DA, Keohane CA, et al. Medication errors in paediatric outpatients. BMJ Qual Saf.
2010;19(6). doi:10.1136/qshc.2008.031179.
https://psnet.ahrq.gov/issue/medication-errors-paediatric-outpatients
Pediatric medication errors are common …
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psnet.ahrq.gov/issue/improving-pain-management-hospitalized-medical-patients
May 01, 2023 - Toolkit
Improving Pain Management for Hospitalized Medical Patients.
Citation Text:
Society of Hospital Medicine. Improving Pain Management for Hospitalized Medical Patients.
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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/issue/nrcpr-project-information-medical-emergencyrapid-response-teams-metrrt
March 29, 2006 - Tools/Toolkit
Toolkit
Published March 29, 2006
NRCPR Project Information: Medical Emergency/Rapid Response Teams (MET/RRT).
National Registry of CPR; Amercan Heart Association; NRCPR; AHA
Topics
…
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psnet.ahrq.gov/node/46624/psn-pdf
November 29, 2017 - Empowerment failure: how shortcomings in physician
communication unwittingly undermine patient autonomy.
November 29, 2017
Ubel PA, Scherr KA, Fagerlin A. Empowerment Failure: How Shortcomings in Physician Communication
Unwittingly Undermine Patient Autonomy. Am J Bioeth. 2017;17(11):31-39.
doi:10.1080/15265161.20…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - Spotlight Case July 2008
Spotlight Case October 2010
Dangerous Dialysis
*
*
Source and Credits
This presentation is based on the October 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - and institutional administration may better address the impact of medical errors on caregivers at all stages
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psnet.ahrq.gov/node/612828/psn-pdf
February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications
February 23, 2022
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
Objectives
Recognition, early evaluation, and management of kidney …
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psnet.ahrq.gov/node/49425/psn-pdf
November 01, 2003 - Defenses could be built in at many stages, depending on the outcome of the investigation.
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psnet.ahrq.gov/node/40167/psn-pdf
January 22, 2017 - Trainees' perceptions of patient safety practices:
recounting failures of supervision.
January 22, 2017
Ross PT, McMyler ET, Anderson SG, et al. Trainees' perceptions of patient safety practices: recounting
failures of supervision. Jt Comm J Qual Patient Saf. 2011;37(2):88-95.
https://psnet.ahrq.gov/issue/trainees…
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/node/45893/psn-pdf
August 28, 2017 - Exploring the roots of unintended safety threats
associated with the introduction of hospital ePrescribing
systems and candidate avoidance and/or mitigation
strategies: a qualitative study.
August 28, 2017
Mozaffar H, Cresswell K, Williams R, et al. Exploring the roots of unintended safety threats associated with
…
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psnet.ahrq.gov/node/43388/psn-pdf
July 30, 2014 - Exploration of an automated approach for receiving
patient feedback after outpatient acute care visits.
July 30, 2014
Berner ES, Ray MN, Panjamapirom A, et al. Exploration of an automated approach for receiving patient
feedback after outpatient acute care visits. J Gen Intern Med. 2014;29(8):1105-12. doi:10.1007/s1…
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psnet.ahrq.gov/node/42968/psn-pdf
February 26, 2014 - From physician intent to the pharmacy label: prevalence
and description of discrepancies from a cross-sectional
evaluation of electronic prescriptions.
February 26, 2014
Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and
description of discrepancies from a cross-se…
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psnet.ahrq.gov/node/37838/psn-pdf
June 11, 2008 - Mitigation of patient harm from testing errors in family
medicine offices: a report from the American Academy of
Family Physicians National Research Network.
June 11, 2008
Graham DG, Harris DM, Elder NC, et al. Mitigation of patient harm from testing errors in family medicine
offices: a report from the American Ac…
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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…