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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Longer
tracheostomy tubes may be placed in the distal intact trachea to bypass areas of
dilation, as
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psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
April 01, 2008 - Most importantly, hospitals and health care systems should aim to consolidate the process into areas
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psnet.ahrq.gov/node/49822/psn-pdf
March 01, 2018 - management aspects of
this case and offer recommendations (Table) to help clinicians avoid common areas
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - cross-cover events that have occurred overnight
and also reviews written signout provided to identify areas
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psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
January 01, 2024 - All hospital
intraoperative records have surgical count documentation areas and during an operation
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - that every step in a diagnostic or treatment pathway is followed, and they are now applied in many areas
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - rating system gives each organization (e.g., hospital or nursing home) a star score from 1 to 5 based on areas
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psnet.ahrq.gov/node/33807/psn-pdf
May 01, 2016 - They do this in other areas of industry.
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psnet.ahrq.gov/curated-library/organizational-learning
May 04, 2025 - Its areas of focus include culture, leadership, and governance, patient and family engagement, workforce
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - patients are attended and monitored during procedural sedation varies substantially across clinical areas … outside the
operating room reported that miscommunication rates were highest in the ED and in those areas
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psnet.ahrq.gov/node/60241/psn-pdf
February 24, 2022 - and COVID-19
COVID-19 created challenges for the NH industry, revealing and amplifying significant areas … Organizations (QIOs), particularly for low-performing NHs or Special Focus Facilities and those in rural
areas … education to NHs with high
positivity rates in late July 2020.40 The teams were to focus on four key areas
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psnet.ahrq.gov/issue/acr-white-paper-magnetic-resonance-mr-safety-combined-papers-2002-and-2004
August 13, 2008 - Commentary
ACR White Paper on Magnetic Resonance (MR) Safety: Combined Papers of 2002 and 2004.
Citation Text:
Kanal E; Borgstede JP; Barkovich AJ; Bell C; Bradley WG; Etheridge S; Felmlee JP; Froelich JW; Hayden J; Kaminski EM; Lester JW Jr; Scoumis EA; Zaremba LA; Zinninger MD; Ameri…
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psnet.ahrq.gov/issue/risk-management-radiology-departments
January 03, 2007 - Review
Risk management in radiology departments.
Citation Text:
Craciun H, Mankad K, Lynch J. Risk management in radiology departments. World J Radiol. 2015;7(6):134-8. doi:10.4329/wjr.v7.i6.134.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote …
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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - Inadvertent Castration
January 1, 2004
Calland FJ. Inadvertent Castration. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/inadvertent-castration
The Case
An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently
increased in size. The patient described persisten…
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Chemotherapy Administration Safety Standards
Citation Text:
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/web-mm/did-we-forget-something
April 28, 2021 - Did We Forget Something?
Citation Text:
Gibbs VC. Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/node/49589/psn-pdf
August 01, 2009 - Hiding in Plain Sight
August 1, 2009
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/hiding-plain-sight
The Case
A 65-year-old woman presented to an emergency department (ED) with 48 hours of nontraumatic left lower
back pain and general malaise. She was diagnosed with a …
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
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 safety field. Last reviewed in…