The PSNet Collection

The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

Displaying 1 - 11 of 11 Results

Patient Safety Essentials for Laboratory Professionals Certificate Program.

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American Association for Clinical Chemistry; AACC.

This certificate program for laboratory professionals offers six courses aimed at enhancing participants' skills in establishing a just culture, identifying safety hazards, and assessing gaps in processes to reduce risks of specimen management errors.

ISMP medication error report analysis.

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Cohen MR, Smetzer JL. Hosp Pharm. 2009;44(10):847-853.

This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.

ISMP medication error report analysis.

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Cohen MR.

This monthly selection of error reports shares examples of topical anesthetic error, methotrexate overdose, and child-proof medicine cap dangers.

ISMP medication error report analysis.

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Cohen MC. Hosp Pharm. 2009;44(5):374-378.

This monthly selection of medication error reports includes examples of drug name confusion, communication failures, and insulin pen misuse.

ISMP medication error report analysis.

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Smetzer JL; Cohen MR.

This monthly selection of error reports includes examples of confusion regarding medication delivery instructions and sound-alike mistakes involving epinephrine and ephedrine.

ISMP medication error report analysis.

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Smetzer JL, Cohen MR. Hosp Pharm. 2008;43(10);788-792.

This monthly selection of reports includes errors involving epidural medication administered intravenously and mistaken reuse of discontinued drugs.

ISMP medication error report analysis.

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Cohen MR.

This monthly selection of medication error reports describes a case of misidentifying home medications for a hospitalized patient, how character space limitations in medication administration records may cause medication errors, and fatal misuse of a fentanyl patch on a child.

ISMP medication error report analysis.

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Cohen MR; Smetzer JL.

This monthly analysis examines recently reported errors in prescribing fentanyl patches, ordering insulin, and administering vincristine.

Right Patient, Wrong Sample

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WebM&M Case December 1, 2006

A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient.

Get me out alive.

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Feldman R

In this article, a nurse shares her firsthand account of what it was like to be a surgical patient and the surprising safety and quality shortcomings she encountered during her hospital stay.

ISMP medication error report analysis.

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Cohen MR.

This monthly selection of medication error reports provides examples from the field of potential errors and helpful tips on how to avoid similar mistakes.

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