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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73456/psn-pdf
    June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia June 30, 2021 Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…

  2. Safeguarding Diagnostic Testing at the Point of Care | PSNet

    psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
    September 30, 2011 - Safeguarding Diagnostic Testing at the Point of Care Citation Text: Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841139/psn-pdf
    December 14, 2022 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. December 14, 2022 Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. PSNet [internet]. 2022. https://psnet.ah…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49699/psn-pdf
    February 01, 2014 - Multifactorial Medication Mishap February 1, 2014 Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Id…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…

  6. Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. | PSNet

    psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
    October 27, 2021 - Study Classic Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Citation Text: Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…

  7. Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals? | PSNet

    psnet.ahrq.gov/issue/using-harm-based-weights-ahrq-patient-safety-selected-indicators-composite-psi-90-does-it
    March 15, 2016 - Study Using harm-based weights for the AHRQ Patient Safety for Selected Indicators composite (PSI-90): does it affect assessment of hospital performance and financial penalties in Veterans Health Administration hospitals? Citation Text: Chen Q, Rosen AK, Borzecki A, et al. Using Harm-Bas…

  8. There is an app for that: mobile technology improves complication reporting and resident perception of their role in patient safety | PSNet

    psnet.ahrq.gov/innovation/there-app-mobile-technology-improves-complication-reporting-and-resident-perception
    November 28, 2012 - EMERGING INNOVATIONS There is an app for that: mobile technology improves complication reporting and resident perception of their role in patient safety Citation Text: Johnson CR, Noorzad A, Pujari A, et al. There is an app for that: mobile technology improves complication reporting and resident p…

  9. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet

    psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery Citation Text: Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

  10. Safety by Design. | PSNet

    psnet.ahrq.gov/issue/safety-design
    March 11, 2009 - Special or Theme Issue Safety by Design. Citation Text: Safety by Design. Qual Saf Health Care. 2006 Dec;15(Suppl 1):i1-90. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy …

  11. Special Issue on Simulation. | PSNet

    psnet.ahrq.gov/issue/special-issue-simulation
    May 01, 2013 - Special or Theme Issue Special Issue on Simulation. Citation Text: Special Issue on Simulation. BMJ Qual Saf. 2013;22(6):449-519. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin…

  12. A pinpoint beam strays invisibly, harming instead of healing. | PSNet

    psnet.ahrq.gov/issue/pinpoint-beam-strays-invisibly-harming-instead-healing
    March 09, 2011 - Newspaper/Magazine Article A pinpoint beam strays invisibly, harming instead of healing. Citation Text: A pinpoint beam strays invisibly, harming instead of healing. Bogdanich W; Rebelo K. Copy Citation Save Save to your library Print Download PDF …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47570/psn-pdf
    December 05, 2018 - An electronic health record–based real-time analytics program for patient safety surveillance and improvement. December 5, 2018 Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff (Millwood). 2018;37(11):1805-181…

  14. Patient Safety Awareness Week. | PSNet

    psnet.ahrq.gov/issue/patient-safety-awareness-week
    July 12, 2017 - Webinar Patient Safety Awareness Week. Citation Text: Patient Safety Awareness Week. Institute for Healthcare Improvement. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

  15. Statement on the prevention of retained foreign bodies after surgery. | PSNet

    psnet.ahrq.gov/issue/statement-prevention-retained-foreign-bodies-after-surgery
    October 15, 2018 - Organizational Policy/Guidelines Statement on the prevention of retained foreign bodies after surgery. Citation Text: Statement on the prevention of retained foreign bodies after surgery. Chicago, IL: American College of Surgeons; October 2016. Copy Citation Save …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42063/psn-pdf
    January 06, 2018 - Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. January 6, 2018 Shekelle PG, Wachter RM, Pronovost PJ, et al. Making Health Care Safer Ii: An Updated Critical Analysis Of The Evidence For Patient Safety Practices.; 2013:Evid Rep Technol Assess (Full Rep).(211)…

  17. Why worry about near misses? | PSNet

    psnet.ahrq.gov/issue/why-worry-about-near-misses
    February 11, 2014 - Newspaper/Magazine Article Why worry about near misses? Citation Text: Why worry about near misses? Marella WM. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

  18. Creating high reliability: a new approach for patient safety. | PSNet

    psnet.ahrq.gov/issue/creating-high-reliability-new-approach-patient-safety
    April 07, 2022 - Commentary Creating high reliability: a new approach for patient safety. Citation Text: McGinnis L. Creating high reliability: a new approach for patient safety. AORN J. 2011;94(3):219-22. doi:10.1016/j.aorn.2011.05.016. Copy Citation Format: DOI Google Scholar PubMed Bib…

  19. Quality and Safety Education. | PSNet

    psnet.ahrq.gov/issue/quality-and-safety-education
    September 06, 2017 - Special or Theme Issue Quality and Safety Education. Citation Text: Quality and Safety Education. Dolansky MA, Singh MK, eds. Qual Manag Health Care. 2009;18(3):149-227. Copy Citation Save Save to your library Print Download PDF Share Fa…

  20. ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations. | PSNet

    psnet.ahrq.gov/issue/ismp-list-error-prone-abbreviations-symbols-and-dose-designations
    January 14, 2024 - Fact Sheet/FAQs ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations. Citation Text: ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations. Horsham, PA; Institute for Safe Medication Practices; April 17, 2024. Copy Citation Save …
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