-
psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Debriefing for Clinical Learning
November 18, 2021
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/debriefing-clinical-learning
Updated in September 2021. Originally published in December 2011 by researchers at the University of
California, S…
-
psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - patients, providing natural light and minimizing nocturnal awakenings, and encouraging mobility.16-19
Approaches
-
psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - Approaches to Improving Safety
Standardized Processes for Infant Feeding
Expressed breast milk being
-
psnet.ahrq.gov/node/33787/psn-pdf
January 01, 2018 - But to me it's a leadership system to define the two approaches and to get the call right.
-
psnet.ahrq.gov/node/72614/psn-pdf
March 01, 2021 - This innovation uses core patient safety communication and teamwork competencies and simulation
approaches
-
psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Approaches to Improving Patient Safety Educate patients about the dangers of super obesity The prevalence
-
psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - organizations have safeguards in place to prevent patient harm from errors in the PN-use process.( 8 ) Approaches
-
psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - List approaches to enhance closed-loop communication between remote telemetry monitoring staff and bedside
-
psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - Approaches to Improving Patient Safety Avoid injecting drugs and air bubbles into arterial lines All
-
psnet.ahrq.gov/node/33647/psn-pdf
March 01, 2007 - The Role of the Patient in Improving Patient Safety
March 1, 2007
Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
Perspective
Patients have three roles in improving patient safety: helping to ensure thei…
-
psnet.ahrq.gov/node/33613/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—II. The Duke Experience
May 1, 2005
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSNet
[internet]. 2005.
https://psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
Pe…
-
psnet.ahrq.gov/node/49790/psn-pdf
April 01, 2017 - Patient Allergies and Electronic Health Records
April 1, 2017
Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
The Case
A 40-year-old woman presented with recurring intense right upper quadrant pain, whi…
-
psnet.ahrq.gov/node/33799/psn-pdf
January 01, 2015 - Burnout Among Health Professionals and Its Effect on
Patient Safety
January 1, 2015
Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
Annual Perspective 2015
Bur…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
February 01, 2018 - PowerPoint Presentation
Spotlight
Signout Fallout
1
Source and Credits
This presentation is based on the February 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…
-
psnet.ahrq.gov/node/49652/psn-pdf
May 01, 2012 - Double Dose at Transfer
May 1, 2012
Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/double-dose-transfer
The Case
A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department
(ED) for left lower extremity pain, swelling, and erythe…
-
psnet.ahrq.gov/node/49800/psn-pdf
July 01, 2017 - The Hidden Harms of Hand Sanitizer
July 1, 2017
Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
The Case
A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital
for community-acquired pn…
-
psnet.ahrq.gov/node/49603/psn-pdf
June 01, 2010 - Fatal Error in Neonate: Does "Just Culture" Provide an
Answer?
June 1, 2010
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
Case Objectives
Describe the just culture approach to in…
-
psnet.ahrq.gov/web-mm/no-blood-please
January 14, 2011 - No Blood, Please
Citation Text:
Liang BA. No Blood, Please. 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
…
-
psnet.ahrq.gov/node/49764/psn-pdf
June 01, 2016 - Communication With Consultants
June 1, 2016
Cohn SL. Communication With Consultants. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/communication-consultants
The Case
A 30-year-old pregnant woman presented to the emergency department (ED) with nausea, headaches, and
fevers. Her laboratory studies were nota…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Bad Writing, Wrong Medication
*
*
Source and Credits
This presentation is based on the April 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Beth Devine, PharmD, MBA, PhD
University of Washingto…