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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/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/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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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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…
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psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - Extravasation may be categorized into 4 stages according to the severity of the injury, as described
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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.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…
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psnet.ahrq.gov/node/49813/psn-pdf
January 01, 2018 - While palliative care may be beneficial for patients at various stages of serious illness, to be
eligible
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psnet.ahrq.gov/web-mm/misread-label
August 28, 2024 - Defenses could be built in at many stages, depending on the outcome of the investigation.
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psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - Never Events
September 15, 2024
Never Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/never-events
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 in 2024.
Backg…
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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/33594/psn-pdf
November 18, 2021 - Debriefing for Clinical Learning
November 18, 2021
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/debriefing-clinical-learning
Updated in September 2021. Originally published in December 2011 by researchers at the University of
California, S…
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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/web-mm/dying-hospital-advanced-dementia
November 01, 2016 - While palliative care may be beneficial for patients at various stages of serious illness, to be eligible
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - SPOTLIGHT CASE
Antiseizure Medication Disorder
Citation Text:
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX En…
-
psnet.ahrq.gov/node/49835/psn-pdf
January 01, 2020 - Don't Pick the PICC
July 1, 2018
McGill RL. Don't Pick the PICC. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/dont-pick-picc
The Case
A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy;
glaucoma; and stage IV chronic kidney disease was admitted to the hospita…