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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
    November 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case November 2005 Reconciling Doses Source and Credits This presentation is based on the November 2005 Spotlight Case in Emergency Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Frank Federico, RPh,…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49410/psn-pdf
    July 01, 2003 - A Little Shuteye July 1, 2003 Farion KJ. A Little Shuteye. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/little-shuteye The Case A 3-year-old boy was seen in urgent care for a superficial laceration above the left eyebrow. The pediatrician had heard of the availability of topical skin adhesive that can be…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49667/psn-pdf
    October 01, 2012 - Looking for Meds in All the Wrong Places October 1, 2012 Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places The Case A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She went to t…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33781/psn-pdf
    March 01, 2015 - In Conversation With… Brian Jarman, PhD March 1, 2015 In Conversation With… Brian Jarman, PhD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-brian-jarman-phd Editor's note: Sir Brian Jarman is an emeritus professor at Imperial College School of Medicine and a past president of the Britis…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33713/psn-pdf
    June 01, 2011 - The Safety of Medical Devices June 1, 2011 Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/safety-medical-devices Perspective Edward Tenner is right. Technology does have reverberations, including unintended consequences, or "revenge effects."(1) While such dra…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33617/psn-pdf
    August 01, 2005 - In Conversation with…Barbara A. Blakeney, MS, RN August 1, 2005 In Conversation with…Barbara A. Blakeney, MS, RN. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn Editor's Note: Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses Associa…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49421/psn-pdf
    October 01, 2003 - Urine a Tough Position October 1, 2003 Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/urine-tough-position The Case A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although she did not want to have a baby at that time, she sta…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49767/psn-pdf
    August 21, 2016 - Falling Between the Cracks in the Software August 21, 2016 Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/falling-between-cracks-software The Case A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33627/psn-pdf
    February 01, 2006 - Removing Insult from Injury—Disclosing Adverse Events February 1, 2006 Wu AW. Removing Insult from Injury—Disclosing Adverse Events. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events Perspective You pull into a parking space, swing open the car door, and ar…
  10. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
    June 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case June 2004 The Wrong Shot: Error Disclosure Source and Credits This presentation is based on the June 2004 AHRQ WebM&M Spotlight Case in Pediatrics CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Commentary by: Thomas H. …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836878/psn-pdf
    April 27, 2022 - The Media’s Role in Patient Safety April 27, 2022 Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/medias-role-patient-safety Brief History of the Media Influencing Patient Safety Despite studies raising questions about avoidable ha…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33641/psn-pdf
    November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again November 1, 2006 Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again Perspective Certain phrases ar…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867004/psn-pdf
    October 30, 2024 - Critical Radiology Alert Process October 30, 2024 https://psnet.ahrq.gov/innovation/critical-radiology-alert-process Summary Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of unrelated abnormal findings and provides a companion follow-up process, with the goal o…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33753/psn-pdf
    August 22, 2013 - Update on Safety Culture August 22, 2013 Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/update-safety-culture Perspective Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians treat each other with r…
  15. psnet.ahrq.gov/perspective/update-patient-engagement-safety
    January 01, 2017 - Annual Perspective Update: Patient Engagement in Safety Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2018  View more articles from the same authors. Citation Text: Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. Rockvi…
  16. psnet.ahrq.gov/primer/triggers-and-trigger-tools
    September 15, 2024 - Triggers and Trigger Tools Citation Text: Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
  17. psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
    December 15, 2024 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events Citation Text: Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cit…
  18. psnet.ahrq.gov/primer/high-reliability
    January 29, 2020 - High Reliability Citation Text: High Reliability. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downl…
  19. psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
    September 27, 2023 - a way to prevent the loss of vital information while better engaging the patient and family. 24,25 Approaches
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850673/psn-pdf
    June 14, 2023 - care, about how to partner, how to listen deeply to patients and families, and how to weave these approaches

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