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  1. psnet.ahrq.gov/web-mm/need-eat
    February 10, 2021 - The Need to Eat Citation Text: Widaman AM. The Need to Eat. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50755/psn-pdf
    December 18, 2019 - The Need to Eat December 18, 2019 Widaman AM. The Need to Eat. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/need-eat The Case A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867672/psn-pdf
    February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations February 26, 2025 Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. 2025. https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867651/psn-pdf
    February 26, 2025 - Safety I, Safety II, and the New Views of Safety February 26, 2025 Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety Background and Context Safety I and Safety II (Safety I/II) are not safety method…
  5. psnet.ahrq.gov/issue/proportion-errors-medical-prescriptions-and-their-executions-among-hospitalized-children-and
    June 15, 2012 - Study The proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation. Citation Text: Mekory TM, Bahat H, Bar-Oz B, et al. The proportion of errors in medical prescriptions and their executions among hospitalized children…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73255/psn-pdf
    May 12, 2021 - Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. May 12, 2021 National Academies of Sciences, Engineering, and Medicine 2021. Washington, DC: The National Academies Press. https://psnet.ahrq.gov/issue/implementing-high-quality-primary-care-rebuilding-foundation-health-care Primary…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47819/psn-pdf
    March 13, 2019 - "Does your knee make more of a click or a clack?"; teaching "Car Talk" to new docs. March 13, 2019 Chisholm P. Health Shots. National Public Radio. February 27, 2019. https://psnet.ahrq.gov/issue/does-your-knee-make-more-click-or-clack-teaching-car-talk-new-docs Problem solving is a key skill for diagnosticians to…
  8. psnet.ahrq.gov/web-mm/double-trouble
    August 01, 2012 - Since the patient’s prior diabetic history is not described, we do not know whether he was started on
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - senior resident on the neurosurgical service told the intern during the day that "heparin should be started
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38477/psn-pdf
    October 03, 2017 - Serious Adverse Events Reports. October 3, 2017 The Quality Improvement Committee. Wellington, New Zealand; 2006-2013. https://psnet.ahrq.gov/issue/serious-adverse-events-reports Considered a starting point for a national reporting initiative, this series of annual reports provides statistics on serious and sentin…
  11. psnet.ahrq.gov/issue/effect-structured-medication-review-followed-face-face-feedback-prescribers-adverse-drug
    January 18, 2013 - Study The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study. Citation Text: Klopotowska JE, Kuks PFM, Wierenga PC, et al. The effect o…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47767/psn-pdf
    June 12, 2019 - Gaps in ambulatory patient safety for immunosuppressive specialty medications. June 12, 2019 Patterson S, Schmajuk G, Evans M, et al. Gaps in Ambulatory Patient Safety for Immunosuppressive Specialty Medications. Jt Comm J Qual Patient Saf. 2019;45(5):348-357. doi:10.1016/j.jcjq.2018.12.003. https://psnet.ahrq.gov…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837077/psn-pdf
    May 11, 2022 - At US hospitals, a drug mix-up is just a few keystrokes away. May 11, 2022 Kelman B. Kaiser Health News. April 29, 2022. https://psnet.ahrq.gov/issue/us-hospitals-drug-mix-just-few-keystrokes-away Technological solutions harbor unique risks that can result in patient harm. This article shares a response to report…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33787/psn-pdf
    January 01, 2018 - conversation-maureen-bisognano http://www.ihi.org/Pages/default.aspx http://dx.doi.org/10.1377/hlthaff.27.3.759 RW: When you started
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33668/psn-pdf
    May 01, 2008 - Robert Wachter, Editor, AHRQ WebM&M: Reflecting back to when you started this work 15 years ago or so
  16. psnet.ahrq.gov/web-mm/comanagement-whos-charge
    July 01, 2011 - He was started on broad-spectrum antibiotics; however, the patient's respiratory status continued to
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39418/psn-pdf
    March 31, 2010 - Take Charge of Your Hospital Stay to Avoid Medical Mistakes. March 31, 2010 Clarke S, Savard M. Good Morning America. ABC News. March 22, 2010. https://psnet.ahrq.gov/issue/take-charge-your-hospital-stay-avoid-medical-mistakes This television interview offers recommendations for patients to keep themselves safe wh…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42534/psn-pdf
    August 28, 2013 - Risk factors for hospital admissions associated with adverse drug events. August 28, 2013 Kongkaew C, Hann M, Mandal J, et al. Risk factors for hospital admissions associated with adverse drug events. Pharmacotherapy. 2013;33(8):827-37. doi:10.1002/phar.1287. https://psnet.ahrq.gov/issue/risk-factors-hospital-admi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39599/psn-pdf
    December 27, 2014 - The role of housestaff in implementing medication reconciliation on admission at an academic medical center. December 27, 2014 Evans AS, Lazar EJ, Tiase VL, et al. The role of housestaff in implementing medication reconciliation on admission at an academic medical center. Am J Med Qual. 2011;26(1):39-42. doi:10.1…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40349/psn-pdf
    May 11, 2011 - Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre. May 11, 2011 Bethune R, Sasirekha G, Sahu A, et al. Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre. Postgrad Med J. 2…

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