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201. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49604/psn-pdf
     June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…

202. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49696/psn-pdf
     December 01, 2013 - New Oral Anticoagulants December 1, 2013 Fang MC. New Oral Anticoagulants. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/new-oral-anticoagulants Case Objectives Review properties of newer target-specific oral anticoagulants (TSOACs) such as dabigatran, rivaroxaban, and apixaban. State key perioperative c…

203. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49794/psn-pdf
     May 01, 2017 - Communication Error in a Closed ICU May 1, 2017 Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/communication-error-closed-icu The Case A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney transplant), co…

204. Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills. | PSNet
     psnet.ahrq.gov/issue/embracing-errors-simulation-based-training-effect-error-training-retention-and-transfer
     May 23, 2013 - Study Embracing errors in simulation-based training: the effect of error training on retention and transfer of central venous catheter skills. Citation Text: Gardner AK, Abdelfattah K, Wiersch J, et al. Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retent…

205. A hybrid methodology for modeling risk of adverse events in complex health-care settings. | PSNet
     psnet.ahrq.gov/issue/hybrid-methodology-modeling-risk-adverse-events-complex-health-care-settings
     November 11, 2015 - Study A hybrid methodology for modeling risk of adverse events in complex health-care settings. Citation Text: Kazemi R, Mosleh A, Dierks M. A Hybrid Methodology for Modeling Risk of Adverse Events in Complex Health-Care Settings. Risk Anal. 2017;37(3):421-440. doi:10.1111/risa.12702. …

206. Improving patient safety in intensive care units in Michigan. | PSNet
     psnet.ahrq.gov/issue/improving-patient-safety-intensive-care-units-michigan
     February 17, 2011 - Study Classic Improving patient safety in intensive care units in Michigan. Citation Text: Pronovost P, Berenholtz SM, Goeschel CA, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-212. doi:10.1016/j.jcrc.2007.09…

207. The wisdom and justice of not paying for "preventable complications." | PSNet
     psnet.ahrq.gov/issue/wisdom-and-justice-not-paying-preventable-complications
     January 22, 2014 - Commentary Classic The wisdom and justice of not paying for "preventable complications." Citation Text: Pronovost P, Goeschel CA, Wachter R. The wisdom and justice of not paying for "preventable complications". JAMA. 2008;299(18):2197-9. doi:10.1001/jama.299.1…

208. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. | PSNet
     psnet.ahrq.gov/issue/collaborative-cohort-study-intervention-reduce-ventilator-associated-pneumonia-intensive-care
     September 20, 2011 - Study Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Citation Text: Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive …

209. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45533/psn-pdf
     November 02, 2016 - Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. November 2, 2016 Power M, Brewster L, Parry G, et al. Multimethod study of a large-scale programme to improve patient safety using a harm-free care approach. BMJ Open. 2016;6(9):e011886. doi:10.1136/bmjopen-2016-…

210. Hyponatremia Secondary to Home Parenteral Nutrition Error | PSNet
     psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
     May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error Citation Text: Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: …

211. Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. | PSNet
     psnet.ahrq.gov/issue/safety-committees-need-proactively-address-risk-accidental-cerebral-injection-intravenous-iv
     January 27, 2021 - Newspaper/Magazine Article Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. Citation Text: Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. ISMP Medication …

212. Adverse Event | PSNet
     psnet.ahrq.gov/taxonomy/term/3437
     May 23, 2025 - Adverse Event Any injury caused by medical care. Examples: pneumothorax from central venous catheter placement anaphylaxis to penicillin postoperative wound infection hospital-acquired delirium (or "sundowning") in elderly patients Identifying something as an adverse event does not imply "error," "negligence," or po…

213. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49657/psn-pdf
     July 01, 2012 - Not-So-Therapeutic Tap July 1, 2012 Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/not-so-therapeutic-tap Case Objectives Describe current issues with training clinicians to perform procedures. Understand how simulation can be used to ensure trainees are competent in proc…

214. The Danger of 10% Intravenous Calcium Chloride Extravasation. | PSNet
     psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
     April 24, 2024 - The Danger of 10% Intravenous Calcium Chloride Extravasation. Citation Text: The Danger of 10% Intravenous Calcium Chloride Extravasation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Goog…

215. 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…

216. Methicillin-resistant Staphylococcus aureus central line–associated bloodstream infections in US intensive care units, 1997-2007. | PSNet
     psnet.ahrq.gov/issue/methicillin-resistant-staphylococcus-aureus-central-line-associated-bloodstream-infections-us
     April 05, 2013 - Study Methicillin-resistant Staphylococcus aureus central line–associated bloodstream infections in US intensive care units, 1997-2007. Citation Text: Burton DC, Edwards JR, Horan TC, et al. Methicillin-resistant Staphylococcus aureus central line-associated bloodstream infections in U…

217. Intervention to reduce transmission of resistant bacteria in intensive care. | PSNet
     psnet.ahrq.gov/issue/intervention-reduce-transmission-resistant-bacteria-intensive-care
     February 29, 2012 - Study Classic Intervention to reduce transmission of resistant bacteria in intensive care. Citation Text: Huskins C, Huckabee CM, O'Grady NP, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med. 2011;364(15):1407-18…

218. Centers for Medicare and Medicaid Services hospital-acquired conditions policy for central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement. | PSNet
     psnet.ahrq.gov/issue/centers-medicare-and-medicaid-services-hospital-acquired-conditions-policy-central-line
     July 03, 2016 - Study Centers for Medicare and Medicaid Services hospital-acquired conditions policy for central line–associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) shows minimal impact on hospital reimbursement. Citation Text: Calderwood MS, Kawai AT, …

219. Influence of the Comprehensive Unit-based Safety Program in ICUs: evidence from the Keystone ICU project. | PSNet
     psnet.ahrq.gov/issue/influence-comprehensive-unit-based-safety-program-icus-evidence-keystone-icu-project
     January 22, 2016 - Study Influence of the Comprehensive Unit-based Safety Program in ICUs: evidence from the Keystone ICU project. Citation Text: Hsu Y-J, Marsteller JA. Influence of the Comprehensive Unit-based Safety Program in ICUs: Evidence From the Keystone ICU Project. Am J Med Qual. 2016;31(4):349-3…

220. Preventing catheter/tubing misconnections: much needed help is on the way. | PSNet
     psnet.ahrq.gov/issue/preventing-cathetertubing-misconnections-much-needed-help-way
     May 07, 2018 - Newspaper/Magazine Article Preventing catheter/tubing misconnections: much needed help is on the way. Citation Text: Preventing catheter/tubing misconnections: much needed help is on the way. ISMP Medication Safety Alert! Acute care edition! July 15, 2010;15:1-2. Copy Citation …