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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48178/psn-pdf
    January 01, 2020 - ACR guidance document on MR safe practices: updates and critical information 2019. August 14, 2019 ACR Committee on MR Safety, Greenberg TD, Hoff MN, Gilk TB, et al. J Magn Reson Imaging. 2020;51(2):331-338.  https://psnet.ahrq.gov/issue/acr-guidance-document-mr-safe-practices-updates-and-critical-inform…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849661/psn-pdf
    June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery June 28, 2023 Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web…
  3. psnet.ahrq.gov/issue/safety-and-communication-operating-room-safety-questionnaire-after-implementation-blood-borne
    September 23, 2020 - Study Safety and communication in the operating room: a safety questionnaire after the implementation of a blood-borne pathogen exposure checkpoint in the surgical safety checklist preprocedure time-out. Citation Text: Kane P, Marley R, Daney B, et al. Safety and Communication in the Ope…
  4. psnet.ahrq.gov/issue/development-and-evaluation-i-pass-picu-standard-electronic-template-improve-referral
    June 14, 2023 - Study Development and evaluation of I-PASS-to-PICU: a standard electronic template to improve referral communication for inter-facility transfers to the pediatric intensive care unit. Citation Text: Parikh NR, Francisco LS, Balikai SC, et al. Development and evaluation of I-PASS-to-PICU:…
  5. psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
    September 27, 2023 - SPOTLIGHT CASE Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Citation Text: Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.. PSNet [internet]…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49737/psn-pdf
    June 01, 2015 - Unseen Perils of Urinary Catheters June 1, 2015 Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters The Case A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
  7. psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx Spotlight Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See…
  8. psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
    January 31, 2024 - Unseen Perils of Urinary Catheters Citation Text: Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar Bib…
  9. psnet.ahrq.gov/web-mm/near-miss-neonate
    August 15, 2018 - Near Miss With Neonate Citation Text: Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
  10. psnet.ahrq.gov/issue/ashp-ppag-guidelines-providing-pediatric-pharmacy-services-hospitals-and-health-systems
    April 24, 2018 - Commentary ASHP–PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems. Citation Text: Eiland LS, Benner K, Gumpper KF, et al. ASHP-PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems. J Pediatr Pharmacol Ther. 2018…
  11. psnet.ahrq.gov/issue/2008-recommendations-pre-anesthesia-checkout-procedures
    April 22, 2020 - Organizational Policy/Guidelines 2008 Recommendations for Pre-Anesthesia Checkout Procedures.  Citation Text: 2008 Recommendations for Pre-Anesthesia Checkout Procedures.  ASA Committee on Equipment and Facilities. Park Ridge, IL: American Society of Anesthesiologists; 2008.  Copy Cita…
  12. psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
    February 12, 2020 - Diagnostic Overshadowing Dangers Citation Text: Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
  13. psnet.ahrq.gov/issue/breaking-rules-understanding-non-compliance-policies-and-guidelines
    September 24, 2018 - Commentary Breaking the rules: understanding non-compliance with policies and guidelines. Citation Text: Carthey J, Walker S, Deelchand V, et al. Breaking the rules: understanding non-compliance with policies and guidelines. BMJ. 2011;343:d5283. doi:10.1136/bmj.d5283. Copy Citation …
  14. psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error
    April 14, 2011 - Review Emerging Classic Hierarchy and medical error: speaking up when witnessing an error. Citation Text: Peadon R (R), Hurley J, Hutchinson M. Hierarchy and medical error: speaking up when witnessing an error. Safety Sci. 2020;125:104648. doi:10.1016/j.ssci.202…
  15. psnet.ahrq.gov/issue/bundaberg-and-beyond-duty-disclose-adverse-events-patients
    January 12, 2022 - Commentary Bundaberg and beyond: duty to disclose adverse events to patients. Citation Text: Madden B, Cockburn T. Bundaberg and beyond: duty to disclose adverse events to patients. J Law Med. 2007;14(4):501-27. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73899/psn-pdf
    September 29, 2021 - Lost in Transitions of Care: Managing an Opioid- Dependent Patient with Frequent Hospitalizations September 29, 2021 Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/lost-transitions-care…
  17. psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
    January 01, 2018 - A Painful Medication Reconciliation Mishap January 1, 2018 CDC ClinicalPractice Guideline for Prescribing Opioids for Pain - United States, 2022.
  18. psnet.ahrq.gov/perspective/update-patient-engagement-safety
    January 01, 2017 - Annual Perspective Update: Patient Engagement in Safety Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2018  View more articles from the same authors. Citation Text: Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. Rockvi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46831/psn-pdf
    April 18, 2018 - Guideline Summary: Medication Safety. April 18, 2018 Guideline Summary: Medication Safety. AORN J. 2018;107(4):489-494. doi:10.1002/aorn.12096. https://psnet.ahrq.gov/issue/guideline-summary-medication-safety Perioperative medication errors can result in patient harm as well as emotional distress among clinical te…
  20. psnet.ahrq.gov/web-mm/easily-forgotten-tube
    June 01, 2016 - An Easily Forgotten Tube Citation Text: Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

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