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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49489/psn-pdf
    September 01, 2005 - Double Trouble September 1, 2005 Gurwitz JH. Double Trouble. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/double-trouble Case Objectives Appreciate the incidence of adverse drug events in older persons List preventative measures that can be used to minimize medication errors in this population Encourage…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50763/psn-pdf
    December 18, 2019 - Their kids died on the psych ward. They were far from alone, a Times investigation found. December 18, 2019 Karlamangla S. Los Angeles Times. December 1, 2019. https://psnet.ahrq.gov/issue/their-kids-died-psych-ward-they-were-far-alone-times-investigation-found Patient suicide is considered a sentinel event. This …
  3. psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
    January 01, 2019 - and race/ethnicity • Patients with recurrent problematic alcohol use utilize the health system to treat … synthesis of multiple risk factors – Reduce immediate life threats (firearms and dangerous medications) – Treat
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846769/psn-pdf
    March 29, 2023 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. March 29, 2023 Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue The C…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37765/psn-pdf
    May 24, 2015 - The Rebecca O'Malley Report. May 24, 2015 Cork, Ireland: Health Information and Quality Authority; March 21, 2008. https://psnet.ahrq.gov/issue/rebecca-omalley-report This report analyzes the findings of a diagnostic error investigation and provides numerous recommendations to improve standards for treating sympto…
  6. psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
    August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment Citation Text: Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citatio…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60062/psn-pdf
    March 18, 2020 - I thought Daniel was safe with the NHS. He wasn't. March 18, 2020 Calvert J, Arbuthnott G. The Sunday Times (UK). March 1, 2020. https://psnet.ahrq.gov/issue/i-thought-daniel-was-safe-nhs-he-wasnt Front line staff concerns which are not treated with respect can undermine improvement efforts and patient safety. Thi…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60309/psn-pdf
    May 06, 2020 - COVID-19 leads to increased need for dialysis machines. May 6, 2020 Mosley T. Here & Now. Boston Public Radio. April 27, 2020. https://psnet.ahrq.gov/issue/covid-19-leads-increased-need-dialysis-machines Comorbidities can result in unexpected care complexities. This article discusses an emerging challenge for …
  9. psnet.ahrq.gov/web-mm/lethal-cap
    December 19, 2018 - Lethal Cap Citation Text: Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Do…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50701/psn-pdf
    November 26, 2019 - If you try and treat those common risk factors, then you will mitigate those harms in hospitals.
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43337/psn-pdf
    July 09, 2014 - My Medicines. July 9, 2014 Silver Spring, MD: US Food and Drug Administration. Office of Women's Health and National Association of Chain Drug Stores. https://psnet.ahrq.gov/issue/my-medicines This toolkit offers tips for patients to prevent adverse drug events and provides a way to record important medication in…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40989/psn-pdf
    December 07, 2011 - The criminalization of mistakes in nursing. December 7, 2011 Philipsen NC. The Criminalization of Mistakes in Nursing. J Nurs Pract. 2011;7(9):719-726. doi:10.1016/j.nurpra.2011.07.004. https://psnet.ahrq.gov/issue/criminalization-mistakes-nursing This commentary describes how treating medical mistakes in a puniti…
  13. psnet.ahrq.gov/web-mm/preventable-rash
    October 01, 2012 - Failure July 1, 2011 WebM&M Cases Doctor, Don't Treat
  14. psnet.ahrq.gov/web-mm/chemotherapy-extravasation
    September 24, 2010 - DMSO), a free radical scavenger that is applied topically to an extravasation area, has been used to treat
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37680/psn-pdf
    April 09, 2008 - 10 derm mistakes you don't want to make. April 9, 2008 Fox GN. 10 derm mistakes you don't want to make. J Fam Pract. 2008;57(3):162-9. https://psnet.ahrq.gov/issue/10-derm-mistakes-you-dont-want-make This article describes common errors that occur in examining, diagnosing, and treating dermatologic conditions and …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33743/psn-pdf
    December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit December 1, 2012 Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit. PSNet [internet]. 2012. https://psnet.ahrq.gov…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73613/psn-pdf
    August 18, 2021 - Implementing universal suicide risk screening in a pediatric hospital. August 18, 2021 Sullivant SA, Brookstein D, Camerer M, et al. Implementing universal suicide risk screening in a pediatric hospital. Jt Comm J Qual Patient Saf. 2021;47(8):496-502. doi:10.1016/j.jcjq.2021.05.001. https://psnet.ahrq.gov/issue/im…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847058/psn-pdf
    April 05, 2023 - Care Delivery within Community Mental Health Teams. April 5, 2023 Farnborough, UK: Healthcare Safety Investigation Branch; March 2023. https://psnet.ahrq.gov/issue/care-delivery-within-community-mental-health-teams Patient suicide is a sentinel event. This report examines a suicide incident that identified problems…
  19. psnet.ahrq.gov/issue/factors-associated-mental-health-outcomes-among-health-care-workers-exposed-coronavirus
    March 24, 2019 - Study Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. Citation Text: Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 20…
  20. psnet.ahrq.gov/issue/impact-electronic-alert-notification-system-embedded-radiologists-workflow-closed-loop
    November 26, 2014 - Study Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis. Citation Text: Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in radiolo…

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