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psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…
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psnet.ahrq.gov/node/33633/psn-pdf
May 01, 2006 - Patient Safety in the Physician Office Setting
May 1, 2006
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
Perspective
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …
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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/web-mm/fumbled-handoff
September 01, 2006 - Fumbled Handoff
Citation Text:
Vidyarthi A. Fumbled Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/issue/icu-attending-handoff-practices-results-national-survey-academic-intensivists
February 06, 2019 - So many ways to be wrong: completeness and accuracy in a prospective study of OR-to-ICU handoff standardization … 2013
The Accreditation Council for Graduate Medical Education resident duty hour new standards
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psnet.ahrq.gov/issue/validation-second-victim-experience-and-support-tool-revised-neonatal-intensive-care-unit
September 24, 2017 - May 19, 2021
Standardization of pediatric noncardiac operating room to intensive care … to enhance compliance of pro re nata medication orders with Joint Commission medication management standards
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psnet.ahrq.gov/node/37268/psn-pdf
December 16, 2011 - Prevention of wrong-site tooth extraction: clinical
guidelines.
December 16, 2011
Lee JS, Curley AW, Smith RA, et al. Prevention of wrong-site tooth extraction: clinical guidelines. J Oral
Maxillofac Surg. 2007;65(9):1793-9.
https://psnet.ahrq.gov/issue/prevention-wrong-site-tooth-extraction-clinical-guidelines
T…
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psnet.ahrq.gov/node/39585/psn-pdf
June 09, 2010 - Bar code technology and medication administration error.
June 9, 2010
Young J, Slebodnik M, Sands L. Bar Code Technology and Medication Administration Error. J Patient Saf.
2010;6(2):115-120. doi:10.1097/pts.0b013e3181de35f7.
https://psnet.ahrq.gov/issue/bar-code-technology-and-medication-administration-error
This…
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psnet.ahrq.gov/node/42195/psn-pdf
October 08, 2013 - Medication errors in the management of anaphylaxis in a
pediatric emergency department.
October 8, 2013
Benkelfat R, Gouin S, Larose G, et al. Medication errors in the management of anaphylaxis in a pediatric
emergency department. J Emerg Med. 2013;45(3):419-425. doi:10.1016/j.jemermed.2012.11.069.
https://psnet.a…
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psnet.ahrq.gov/node/42826/psn-pdf
December 18, 2013 - Improvement of medication event interventions through
use of an electronic database.
December 18, 2013
Merandi J, Morvay S, Lewe D, et al. Improvement of medication event interventions through use of an
electronic database. Am J Health Syst Pharm. 2013;70(19):1708-14. doi:10.2146/ajhp130021.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/50667/psn-pdf
November 13, 2019 - Proactive prevention of maternal death from maternal
hemorrhage.
November 13, 2019
Quick Safety. October 29, 2019;(51):1-3.
https://psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage
The reduction of postpartum hemorrhage and the overall improvement of maternal safety is a patient safety
…
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psnet.ahrq.gov/node/37240/psn-pdf
December 16, 2011 - Errors in the administration of intravenous medication in
Brazilian hospitals.
December 16, 2011
Anselmi ML, Peduzzi M, dos Santos CB. Errors in the administration of intravenous medication in Brazilian
hospitals. J Clin Nurs. 2007;16(10). doi:10.1111/j.1365-2702.2007.01834.x.
https://psnet.ahrq.gov/issue/errors-a…
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psnet.ahrq.gov/node/844772/psn-pdf
September 18, 2019 - Lyme disease is baffling, even to experts, but new
insights are at last accumulating.
September 18, 2019
O'Rourke M. The Atlantic. September 2019.
https://psnet.ahrq.gov/issue/lyme-disease-baffling-even-experts-new-insights-are-last-accumulating
Diagnostic errors occur due to a variety of factors. This magazine ar…
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psnet.ahrq.gov/node/42703/psn-pdf
December 06, 2013 - Administrative issues to ensure safe anesthesia care in
the office-based setting.
December 6, 2013
Gaulton TG, Shapiro FE, Urman RD. Administrative issues to ensure safe anesthesia care in the office-
based setting. Curr Opin Anaesthesiol. 2013;26(6):692-7. doi:10.1097/ACO.0000000000000005.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/41728/psn-pdf
January 18, 2013 - Who's covering our loved ones: surprising barriers in the
sign-out process.
January 18, 2013
Antonoff MB, Berdan EA, Kirchner VA, et al. Who's covering our loved ones: surprising barriers in the sign-
out process. Am J Surg. 2013;205(1):77-84. doi:10.1016/j.amjsurg.2012.05.009.
https://psnet.ahrq.gov/issue/whos-co…
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psnet.ahrq.gov/node/33839/psn-pdf
August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of
Northwester…
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psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - SPOTLIGHT CASE
The Hazards of Distraction: Ticking All the EHR Boxes
Citation Text:
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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