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  1. psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
    September 23, 2024 - Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 11, 2021 Innovation …
  2. psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
    July 01, 2012 - "Superficial" Report Leads to "Deep" Problem Citation Text: Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndN…
  3. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
    July 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case July 2007 Resuscitation Errors: A Shocking Problem Source and Credits This presentation is based on the July 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available online Commentary by: Benjamin Abella, MD, MPhil, …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49444/psn-pdf
    May 01, 2004 - Do Me a Favor May 1, 2004 Williamson A. Do Me a Favor. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/do-me-favor The Case A 26-year-old gravida 4 para 1 woman reported that her last menstrual period was 5 weeks prior, and she had a positive home pregnancy test. With a history of one ectopic pregnancy, one…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49452/psn-pdf
    July 01, 2004 - Allergy to Holter July 1, 2004 Williams M. Allergy to Holter. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/allergy-holter The Case A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4 the patient was sent to the cardiac clinic to start a continuous …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49734/psn-pdf
    May 01, 2015 - Departure From Central Line Ritual May 1, 2015 Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/departure-central-line-ritual The Case A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33625/psn-pdf
    January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions Remain January 1, 2006 Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain Perspective On August 2, 2005, Air France flig…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33666/psn-pdf
    October 01, 2008 - Methicillin-Resistant Staphylococcus aureus April 1, 2008 Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus Perspective Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72693/psn-pdf
    January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33700/psn-pdf
    October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD October 1, 2010 In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0 Editor's note: Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and He…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49837/psn-pdf
    August 01, 2018 - Abdominal Aortic Aneurysm Screening August 1, 2018 Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening Case Objectives Describe risk factors associated with abdominal aortic aneurysm. Identify patient populations meeting criteria fo…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49459/psn-pdf
    September 01, 2004 - Caution, Interrupted September 1, 2004 Wears RL. Caution, Interrupted. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/caution-interrupted The Case A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and neutropenia presented to the emergency department (ED) with …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72587/psn-pdf
    December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability December 23, 2020 Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49466/psn-pdf
    October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
  15. psnet.ahrq.gov/periodic-issue/periodic-issue-473
    March 25, 2025 - March 5, 2025 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, …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33562/psn-pdf
    September 15, 2024 - Rapid Response Systems September 15, 2024 Rapid Response Systems. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/rapid-response-systems 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.…
  17. psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
    June 16, 2021 - EMERGING INNOVATIONS eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds. Citation Text: Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support duri…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33576/psn-pdf
    December 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editoria…
  19. psnet.ahrq.gov/innovation/implementing-watcher-program-improve-timeliness-recognition-deterioration-hospitalized
    June 30, 2021 - EMERGING INNOVATIONS Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Citation Text: Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Evans S, Green A, Roberson A, et al. …
  20. psnet.ahrq.gov/innovation/awareness-human-factors-operating-theatres-during-covid-19-pandemic
    January 13, 2021 - EMERGING INNOVATIONS Awareness of human factors in the operating theatres during the COVID-19 pandemic Citation Text: Britton CR, Hayman G, Stroud N. Awareness of Human Factors in the operating theatres during the COVID-19 pandemic. Journal of Perioperative Practice. 2020;31(1-2). doi:10.1177/1750…

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