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3441. Patient Safety Authority Annual Reports. | PSNet
      psnet.ahrq.gov/issue/patient-safety-authority-annual-reports
      December 09, 2020 - Book/Report Patient Safety Authority Annual Reports. Citation Text: Patient Safety Authority Annual Reports. Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2024. Copy Citation Save Save to your library Print Downlo…

3442. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. | PSNet
      psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
      July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. Citation Text: Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.. PSNet [internet]. Rockville (MD): A…

3443. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.227_slideshow.ppt
      November 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Treatment Challenges After Discharge * * Source and Credits This presentation is based on the November 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Chase Coffey, MD, Henry Ford Health System,…

3444. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33871/psn-pdf
      December 22, 2018 - Maternal Safety December 22, 2018 Lyndon A. Maternal Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/maternal-safety Annual Perspective 2018 The Context of Maternal Safety Childbirth-related maternal health outcomes have been worsening for some time in the United States. After a dramatic reduc…

3445. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
      October 01, 2008 - Spotlight Case July 2008 Spotlight Case Recurrent Hypoglycemia: A Care Transition Failure? * * Source and Credits This presentation is based on the October 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Ted Eytan, MD, MS, MPH Editor, …

3446. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49652/psn-pdf
      May 01, 2012 - Double Dose at Transfer May 1, 2012 Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/double-dose-transfer The Case A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythe…

3447. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33570/psn-pdf
      June 15, 2024 - Diagnostic Errors June 15, 2024 Diagnostic Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/diagnostic-errors 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. Last reviewed in 20…

3448. Right Regimen, Wrong Cancer: Patient Catches Medical Error | PSNet
      psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
      August 01, 2006 - For example, a hierarchical organizational structure that discourages an employee from communicating

3449. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet
      psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
      March 15, 2023 - tubes, hospitals must adopt protocols outlining routine practices for monitoring cuff pressures and communicating

3450. In Conversation With… Rebecca Lawton, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
      March 24, 2025 - in the work environment, whether staff seemed to be well-trained to do the job, whether staff were communicating

3451. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet
      psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
      July 23, 2024 - It was fully implemented in October 2020. 2   Ascension recognized the importance of communicating about

3452. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet
      psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
      January 29, 2021 - important to ensure that new or junior staff have appropriate onboarding that emphasizes the importance of communicating

3453. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49740/psn-pdf
      August 21, 2015 - Baffled by Botulinum Toxin August 21, 2015 Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/baffled-botulinum-toxin The Case A 5-year-old boy with a history of transverse myelitis with resultant spasticity of both lower extremities, gait abnormalities, neurogeni…

3454. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33876/psn-pdf
      August 01, 2018 - Building a Safety Program in a Vast Health Care Network March 1, 2019 Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network Perspective Background As hospital-based health care in the United …

3455. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73643/psn-pdf
      August 01, 2022 - ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay August 25, 2021 https://psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled- nursing Summary ECHO-Care Transitions (ECHO-CT) intends to ensure cont…

3456. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49826/psn-pdf
      April 01, 2018 - Air on the Side of Caution April 1, 2018 Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/air-side-caution The Case A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of breath and chest pain. A decision was m…

3457. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49827/psn-pdf
      April 01, 2018 - Walking Patient, Missing Drain April 1, 2018 Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain The Case A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective …

3458. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
      February 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case February 2006 Lost in Transition Source and Credits This presentation is based on the February 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Christopher Beach, MD; Northwe…

3459. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49515/psn-pdf
      July 01, 2006 - Over Not So Easy July 1, 2006 Cucina R. Over Not So Easy. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/over-not-so-easy The Case A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On admission, she reported allergies to a number of medications as well as a …

3460. Strategies and Approaches for Tracking Improvements in Patient Safety | PSNet
      psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
      June 15, 2024 - Strategies and Approaches for Tracking Improvements in Patient Safety Citation Text: Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citat…