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6341. ASHP guidelines on the safe use of automated dispensing devices. | PSNet
      psnet.ahrq.gov/issue/ashp-guidelines-safe-use-automated-dispensing-devices
      July 05, 2017 - Organizational Policy/Guidelines ASHP guidelines on the safe use of automated dispensing devices. Citation Text: Cello R, Conley M, Cooley TW, et al. ASHP Guidelines on the Safe Use of Automated Dispensing Cabinets. Am J Health Syst Pharm. 2021;79(1):e71-e82. doi:10.1093/ajhp/zxab325. …

6342. Make no mistake about it: chain pharmacies are finding innovative ways to combat medication errors. | PSNet
      psnet.ahrq.gov/issue/make-no-mistake-about-it-chain-pharmacies-are-finding-innovative-ways-combat-medication
      May 20, 2020 - Newspaper/Magazine Article Make no mistake about it: chain pharmacies are finding innovative ways to combat medication errors. Citation Text: Make no mistake about it: chain pharmacies are finding innovative ways to combat medication errors. Levy S. Drug Topics. July 9, 2007 Copy…

6343. Implementing Optimal Team-Based Care to Reduce Clinician Burnout. | PSNet
      psnet.ahrq.gov/issue/implementing-optimal-team-based-care-reduce-clinician-burnout
      January 16, 2019 - Book/Report Emerging Classic Implementing Optimal Team-Based Care to Reduce Clinician Burnout. Citation Text: Implementing Optimal Team-Based Care to Reduce Clinician Burnout. Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Acade…

6344. In Conversation With… Richard C. Boothman, JD | PSNet
      psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
      March 01, 2012 - In Conversation With… Richard C. Boothman, JD March 1, 2012  Also Read an Essay Citation Text: In Conversation With… Richard C. Boothman, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

6345. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
      psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
      September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please Teryl K. Nuckols, MD, MSHS | September 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Nuckols TK. Incident Reporting: More Attention to the …

6346. In Conversation With… Rebecca Smith-Bindman, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
      October 01, 2013 - In Conversation With… Rebecca Smith-Bindman, MD October 1, 2013  Also Read an Essay Citation Text: In Conversation With… Rebecca Smith-Bindman, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

6347. Safety in Radiology | PSNet
      psnet.ahrq.gov/perspective/safety-radiology
      October 01, 2013 - Safety in Radiology Antonio Pinto, MD, PhD | October 1, 2013  Also Read a Conversation View more articles from the same authors. Citation Text: Pinto A. Safety in Radiology. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…

6348. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49448/psn-pdf
      June 01, 2004 - Listen to the Family June 1, 2004 Campbell D. Listen to the Family. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/listen-family The Case Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The surgical resident examined the patient, an elderly woman with …

6349. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49439/psn-pdf
      March 01, 2004 - Lethal Cap March 1, 2004 Schillinger D. Lethal Cap. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-cap The Case A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…

6350. Spotlight
      psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
      January 01, 2020 - Spotlight Spotlight Suicidal Ideation in the Family Medicine Clinic 1 Source and Credits This presentation is based on the December 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Christine Moutier, MD, Chief Medical Officer, American …

6351. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49409/psn-pdf
      July 01, 2003 - Feeling No Pain July 1, 2003 Bogner MS. Feeling No Pain. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/feeling-no-pain The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…

6352. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33602/psn-pdf
      March 15, 2025 - Individual Clinician Performance Issues March 15, 2025 Individual Clinician Performance Issues. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/individual-clinician-performance-issues PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current res…

6353. Computerized Provider Order Entry and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
      January 01, 2014 - Annual Perspective Computerized Provider Order Entry and Patient Safety Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015  View more articles from the same authors. Citation Text: Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…

6354. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33593/psn-pdf
      June 15, 2024 - Measurement of Patient Safety June 15, 2024 Measurement of Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/measurement-patient-safety 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 …

6355. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866265/psn-pdf
      July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport July 31, 2024 MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…

6356. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867980/psn-pdf
      March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls March 25, 2025 Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls. PSNet [internet]. 2025. https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…

6357. Selection Criteria and Honorarium Information | PSNet
      psnet.ahrq.gov/Webmm/submit-case-info
      August 10, 2025 - Selection Criteria and Honorarium Information How it works Health care professionals may submit de-identified cases that highlight medical errors or other patient safety/quality issues. Note that you can choose to submit cases either …

6358. Application of lean thinking to health care: issues and observations. | PSNet
      psnet.ahrq.gov/issue/application-lean-thinking-health-care-issues-and-observations
      May 28, 2015 - Commentary Application of lean thinking to health care: issues and observations. Citation Text: Joosten T, Bongers I, Janssen R. Application of lean thinking to health care: issues and observations. International Journal for Quality in Health Care. 2009;21(5). doi:10.1093/intqhc/mzp036…

6359. Using an automated risk assessment report to identify patients at risk for clinical deterioration. | PSNet
      psnet.ahrq.gov/issue/using-automated-risk-assessment-report-identify-patients-risk-clinical-deterioration
      February 15, 2017 - Commentary Using an automated risk assessment report to identify patients at risk for clinical deterioration. Citation Text: Whittington J, White R, Haig KM, et al. Using an automated risk assessment report to identify patients at risk for clinical deterioration. Jt Comm J Qual Patient S…

6360. The ethical imperative to think about thinking. | PSNet
      psnet.ahrq.gov/issue/ethical-imperative-think-about-thinking
      June 27, 2018 - Commentary The ethical imperative to think about thinking. Citation Text: Stark M, Fins JJ. The ethical imperative to think about thinking - diagnostics, metacognition, and medical professionalism. Camb Q Healthc Ethics. 2014;23(4):386-96. doi:10.1017/S0963180114000061. Copy Citation …