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psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety
Brian K. Alldredge, PharmD; Mary Anne Koda-Kimble, PharmD | April 1, 2006
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Alldredge BK, Koda-Kimb…
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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.
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psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA
April 1, 2010
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In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - SPOTLIGHT CASE
Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery
Citation Text:
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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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…
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psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications
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psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
August 01, 2010 - In Conversation with...Richard P. Shannon, MD
August 1, 2010
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In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010.In Conversation with...Richard P. Shannon, MD. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD (hon)
April 1, 2006
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In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - SPOTLIGHT CASE
A Loss of Trust and a Missed Diagnosis
Citation Text:
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance
Lance L. Roberts, MS; Marcia M. Ward, PhD; Thomas C. Evans, MD | April 1, 2010
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - Infection After Carpal Tunnel Surgery
August 28, 2024
Szabo RM. Infection After Carpal Tunnel Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
The Case
A woman presented for surgery on her right wrist as a treatment for carpal tunnel syndrome. There were no
repo…
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers
Chayan Chakraborti, MD; Marc J. Kahn, MD; N. Kevin Krane, MD | August 1, 2010
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Chakraborti C, Kahn MJ, Krane K. Operatio…
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psnet.ahrq.gov/node/74149/psn-pdf
January 07, 2022 - Multiple Missed Opportunities for Suicide Risk
Assessment in Emergency and Primary Care Settings
January 7, 2022
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and
Primary Care Settings. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/multiple-missed-opportu…
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - Miscommunication During the Interhospital Transport of a
Critically Ill Child
August 31, 2022
Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-c…
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - Intraosseous Line Extravasation in a Pediatric Trauma
Patient
April 27, 2022
Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE)
Collaborative Studies and Implements Methods to Prevent
Avoidable Cases of Hospital Associated VTE
April 7, 2022
https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-
implements-methods
Summary
Venous thromboembolism (…
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psnet.ahrq.gov/node/853902/psn-pdf
September 27, 2023 - A Missed Bowel Perforation - the Importance of
Diagnostic Reasoning
September 27, 2023
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
Disclosure of …
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - The Michigan Hospital Medicine Safety Consortium (HMS)
Finds Infectious Diseases (ID) Physician Approval for
Placement of Peripherally Inserted Central Catheters
(PICCs) Prevents Unnecessary PICC Use and Reduces
Complications
February 23, 2022
https://psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-co…
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - Infection After Carpal Tunnel Surgery
Citation Text:
Szabo RM. Infection After Carpal Tunnel Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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