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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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,…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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