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8761. Discharged with IV antibiotics: When issues arise, who manages the complications? | PSNet
      psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
      October 10, 2017 - A lead clinician (pharmacist, advanced practice provider, or physician) must take responsibility to actively

8762. In Conversation with...Albert Wu, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
      February 26, 2025 - Some solutions are at the level of making a policy or retraining an individual clinician.

8763. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49588/psn-pdf
      August 01, 2009 - These alternative solutions require clinician teamwork and strict adherence to handoff communication

8764. Crossing the Line | PSNet
      psnet.ahrq.gov/web-mm/crossing-line
      December 01, 2012 - institutional priority to reduce complications of central venous catheterization, (ii) identify a respected clinician

8765. A Painful Medication Reconciliation Mishap | PSNet
      psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
      May 01, 2008 - The primary care clinician in this case recognized the error and appropriately discontinued the naltrexone

8766. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49777/psn-pdf
      December 01, 2016 - recognize mental health issues and what to do to help.(9) In this case, the staff member should have had a clinician

8767. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
      January 01, 2020 - Most injuries occurred within 24h of surgery and were deemed preventable with better monitoring and clinician

8768. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
      June 01, 2003 - PowerPoint Presentation Spotlight Case June 2003 Missed Appendicitis webmm.ahrq.gov Source and Credits This presentation is based on June 2003 AHRQ WebM&M Spotlight Case in Surgery See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: James Adams, MD, Fei…

8769. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50699/psn-pdf
      November 26, 2019 - Patient Safety in Frail Older Patients November 26, 2019 Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients Background Older patients are at a particular risk of experiencing a patient safety event. Stud…

8770. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867804/psn-pdf
      February 26, 2025 - Are We Safer Today? February 26, 2025 Bates DW, Lee M, Mossburg SE. Are We Safer Today? PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/are-we-safer-today In the 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (now the National Academy of Medicine) drew on two lar…

8771. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50610/psn-pdf
      October 30, 2019 - First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit October 30, 2019 Profit J, Scheid A, Ridout E. First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safe…

8772. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49524/psn-pdf
      November 01, 2006 - Secured But Not Always Safe November 1, 2006 Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/secured-not-always-safe The Case An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative osteoarthritis. She received spinal …

8773. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33617/psn-pdf
      August 01, 2005 - In Conversation with…Barbara A. Blakeney, MS, RN August 1, 2005 In Conversation with…Barbara A. Blakeney, MS, RN. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn Editor's Note: Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses Associa…

8774. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33790/psn-pdf
      August 01, 2015 - New Insights on Safety and Health IT August 1, 2015 Hettinger ZA, Ratwani RM, Fairbanks RJ. New Insights on Safety and Health IT. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/new-insights-safety-and-health-it Perspective Despite the widespread adoption of electronic health records (EHRs) over the las…

8775. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
      October 01, 2011 - Spotlight Case [MONTH] 2003 Spotlight Case Mobility Lost in the ICU * * Source and Credits This presentation is based on the October 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jim Smith, PT, DPT, MA; Associate Professor of Physical …

8776. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
      June 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case June 2004 The Wrong Shot: Error Disclosure Source and Credits This presentation is based on the June 2004 AHRQ WebM&M Spotlight Case in Pediatrics CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Commentary by: Thomas H. …

8777. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49689/psn-pdf
      August 21, 2013 - Anesthesia: A Weighty Issue August 21, 2013 Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/anesthesia-weighty-issue The Case A 77-year-old woman was evaluated preoperatively in anticipation of an elective left hip arthroplasty. She reported having a history of hyperte…

8778. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33781/psn-pdf
      March 01, 2015 - In Conversation With… Brian Jarman, PhD March 1, 2015 In Conversation With… Brian Jarman, PhD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-brian-jarman-phd Editor's note: Sir Brian Jarman is an emeritus professor at Imperial College School of Medicine and a past president of the Britis…

8779. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72836/psn-pdf
      January 26, 2021 - Meaningful Measurement in Patient and Family Engagement March 10, 2021 Hoy L, Hoy S, Fitall E, et al. Meaningful Measurement in Patient and Family Engagement. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement Defining Patient and Family Engagement Pat…

8780. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851389/psn-pdf
      July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer Summary Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, a…