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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49791/psn-pdf
    April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable April 1, 2017 Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable The Case An 84-year-old wo…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33797/psn-pdf
    January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice January 1, 2016 Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…
  3. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
    January 01, 2020 - Spotlight Spotlight Inpatient Stroke Management in a Patient with Type 1 Diabetes and Home Insulin Pump Source and Credits • This presentation is based on the October 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Berit B…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49803/psn-pdf
    January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3 August 1, 2017 Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3 The Case A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the app…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72837/psn-pdf
    September 01, 2022 - Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes. Originally published on March 11, 2021 Last updated on March 16, 2021 https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder- improves-maternal-and Summary Project…
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
    May 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case May 2004 Too Tight Control: The Risks of Intensive Insulin Therapy Source and Credits This presentation is based on the May 2004 AHRQ WebM&M Spotlight Case in Medicine CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Comm…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49395/psn-pdf
    April 01, 2003 - Medication Overdose April 1, 2003 Kaushal R. Medication Overdose. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/medication-overdose The Case A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He was diagnosed with status epilepticus and started on a loading…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49700/psn-pdf
    February 01, 2014 - Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients February 1, 2014 Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/nonsustaine…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33659/psn-pdf
    October 01, 2007 - Making Just Culture a Reality: One Organization's Approach October 1, 2007 Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach Perspective We've all been there...something goes wrong,…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33804/psn-pdf
    March 03, 2016 - In Conversation With… Paul McGann, MD March 1, 2016 In Conversation With… Paul McGann, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for Medicare & Medicaid Services (CMS). He…
  11. psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
    June 28, 2023 - SPOTLIGHT CASE A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care Citation Text: Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33830/psn-pdf
    March 22, 2016 - Measuring and Responding to Deaths From Medical Errors March 22, 2016 Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors Annual Perspective 2016 The Prevalence of Deaths Due to Preventable Adve…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33574/psn-pdf
    March 15, 2025 - Ambulatory Care Safety March 15, 2025 Ambulatory Care Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/ambulatory-care-safety 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. Las…
  14. psnet.ahrq.gov/primer/handoffs
    October 18, 2023 - Handoffs Citation Text: Handoffs and Signouts. 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 Download…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39205/psn-pdf
    January 06, 2010 - How Safe Is Your Hospital? January 6, 2010 Dr Foster Intelligence Unit. London, UK: Imperial College London; 2009. https://psnet.ahrq.gov/issue/how-safe-your-hospital This consumer-focused report ranked the 148 hospital trusts in the United Kingdom National Health Service (NHS) on patient safety, clinical effectiv…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36084/psn-pdf
    March 01, 2011 - Alarm algorithms in critical care monitoring. March 1, 2011 Imhoff M, Kuhls S. Alarm algorithms in critical care monitoring. Anesth Analg. 2006;102(5):1525-37. https://psnet.ahrq.gov/issue/alarm-algorithms-critical-care-monitoring The researchers discuss the ineffectiveness of current clinical monitoring systems an…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37235/psn-pdf
    March 04, 2015 - Radiologic errors and malpractice: a blurry distinction. March 4, 2015 Berlin L. Radiologic errors and malpractice: a blurry distinction. AJR Am J Roentgenol. 2007;189(3):517-22. https://psnet.ahrq.gov/issue/radiologic-errors-and-malpractice-blurry-distinction Reviewing legal and clinical literature, the author dis…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33999/psn-pdf
    March 07, 2005 - Center for Consumer Health Care Information Patient Safety Center. March 7, 2005 https://psnet.ahrq.gov/issue/center-consumer-health-care-information-patient-safety-center The Center's efforts for patient safety are highlighted, including New York's Patient Occurrence Reporting and Tracking System, Clinical Guidel…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40607/psn-pdf
    July 13, 2011 - Biomedical Complexity and Error. July 13, 2011 Patel VL, Kahol K, Buchman T, eds. J Biomed Inform. 2011;44:385-506.    https://psnet.ahrq.gov/issue/biomedical-complexity-and-error This special issue explores complexity in error management, clinical workflow, and decision making. https://psnet.ahrq.gov/is…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33858/psn-pdf
    May 01, 2018 - RW: A lot of what you're talking about depends on data moving around from your hospital to your clinic

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