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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33861/psn-pdf
    July 01, 2018 - In Conversation With… Gordon Schiff, MD July 1, 2018 In Conversation With… Gordon Schiff, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-gordon-schiff-md Editor's note: Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, Associate Pr…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49818/psn-pdf
    January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis January 1, 2018 Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis The Case A 50-year-old man presented to a primary care clinic to establish care, as he ha…
  3. psnet.ahrq.gov/Information/Panel
    January 01, 2012 - Browse Author Resources Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
  4. psnet.ahrq.gov/perspective/care-transitions
    December 01, 2007 - Care Transitions Sunil Kripalani, MD, MSc | December 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Kripalani S. Care Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depart…
  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-04/final_april-spotlight-implicit_biases_04.02.2020.pdf
    January 01, 2020 - Spotlight Spotlight Implicit Biases, Interprofessional Communication, and Power Dynamics Source and Credits • This presentation is based on the April 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Erin Stephany Sanchez, MD, Melody Tran- Reina, MD, Kupi…
  6. psnet.ahrq.gov/periodic-issue/periodic-issue-460
    October 30, 2024 - October 9, 2024 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49804/psn-pdf
    September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding September 1, 2017 Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding Case Objectives Describe risk factors for poor outcome in patients w…
  8. psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
    May 01, 2009 - Adverse drug events in ambulatory care. N Engl J Med. 2003;348:1556-1564. [go to PubMed] 2.
  9. psnet.ahrq.gov/periodic-issue/periodic-issue-430
    March 27, 2024 - This qualitative study explored how sociotechnical systems contribute to adverse drug events (ADEs) in
  10. psnet.ahrq.gov/web-mm/case-mistaken-intubation
    July 01, 2016 - SPOTLIGHT CASE The Case of Mistaken Intubation Citation Text: Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX End…
  11. psnet.ahrq.gov/web-mm/air-side-caution
    April 21, 2015 - Air on the Side of Caution Citation Text: Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49536/psn-pdf
    May 01, 2007 - On the Other Hand May 1, 2007 Henneman EA. On the Other Hand. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/other-hand The Case A young woman with Takayasu's arteritis presented to the hospital with severe abdominal pain. The patient had been diagnosed with Takayasu's a decade earlier. The disease results…
  13. psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
    August 14, 2024 - SPOTLIGHT CASE Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. Citation Text: Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837959/psn-pdf
    August 31, 2022 - Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy August 31, 2022 Kelly KJ. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertio…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49783/psn-pdf
    February 01, 2017 - The Hazards of Distraction: Ticking All the EHR Boxes February 1, 2017 Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes Case Objectives List the goals of having order sets in the electronic health record…
  16. psnet.ahrq.gov/perspective/safety-radiology
    October 01, 2013 - February 14, 2024 Evaluation of accuracy of IHI Trigger Tool in identifying adverse drugevents: a prospective observational study.
  17. psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
    September 01, 2003 - Systems analysis of adverse drug events. J Am Med Assoc . 1995;274(1):35-43. Farrell G.
  18. psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
    March 04, 2020 - The Hidden Harms of Hand Sanitizer Citation Text: Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33659/psn-pdf
    October 01, 2007 - Making Just Culture a Reality: One Organization's Approach October 1, 2007 Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach Perspective We've all been there...something goes wrong,…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33689/psn-pdf
    October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety October 1, 2009 Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety Perspective …

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