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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46039/psn-pdf
    April 05, 2017 - Retained lumbar catheter tip. April 5, 2017 DeLancey JO, Barnard C, Bilimoria KY. Retained Lumbar Catheter Tip. JAMA. 2017;317(12):1269-1270. doi:10.1001/jama.2017.1713. https://psnet.ahrq.gov/issue/retained-lumbar-catheter-tip Retained surgical items are considered a sentinel event. Discussing an incident involvi…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42403/psn-pdf
    August 02, 2015 - Encouraging patients to ask questions: how to overcome "white-coat silence." August 2, 2015 Judson TJ, Detsky AS, Press MJ. Encouraging patients to ask questions: how to overcome "white-coat silence". JAMA. 2013;309(22):2325-6. doi:10.1001/jama.2013.5797. https://psnet.ahrq.gov/issue/encouraging-patients-ask-quest…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41634/psn-pdf
    January 31, 2013 - Disclosure of harmful medical errors in out-of-hospital care. January 31, 2013 Lu DW, Guenther E, Wesley AK, et al. Disclosure of harmful medical errors in out-of-hospital care. Ann Emerg Med. 2013;61(2):215-21. doi:10.1016/j.annemergmed.2012.07.004. https://psnet.ahrq.gov/issue/disclosure-harmful-medical-errors-o…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42874/psn-pdf
    January 29, 2014 - Interdisciplinary Perspectives on Medical Error. January 29, 2014 J Public Health Res. 2013;2:e22-e33. https://psnet.ahrq.gov/issue/interdisciplinary-perspectives-medical-error This special issue explores the challenges of advancing patient safety and highlights the value of interdisciplinary collaboration to achi…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42158/psn-pdf
    April 03, 2013 - Long-term effects of a perioperative safety checklist from the viewpoint of personnel. April 3, 2013 Böhmer AB, Kindermann P, Schwanke U, et al. Long-term effects of a perioperative safety checklist from the viewpoint of personnel. Acta Anaesthesiol Scand. 2013;57(2):150-7. doi:10.1111/aas.12020. https://psnet.ahr…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34898/psn-pdf
    April 21, 2011 - Crossing to safety: transforming healthcare organizations for patient safety. April 21, 2011 Ralston JD, Larson EB. Crossing to safety: transforming healthcare organizations for patient safety. J Postgrad Med. 2005;51(1):61-67. https://psnet.ahrq.gov/issue/crossing-safety-transforming-healthcare-organizations-pati…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40230/psn-pdf
    November 23, 2016 - Talking with Patients and Families about Medical Error: A Guide for Education and Practice. November 23, 2016 Truog RD, Browning DM, Johnson JA, Gallagher TH. Baltimore, MD: Johns Hopkins University Press; 2011. ISBN: 0801898048. https://psnet.ahrq.gov/issue/talking-patients-and-families-about-medical-error-guide-…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35776/psn-pdf
    March 10, 2011 - A systematic review of the literature on multidisciplinary rounds to design information technology. March 10, 2011 Gurses AP, Xiao Y. A systematic review of the literature on multidisciplinary rounds to design information technology. J Am Med Inform Assoc. 2006;13(3):267-76. https://psnet.ahrq.gov/issue/systematic…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46490/psn-pdf
    October 29, 2017 - Simulation training in obstetrics. October 29, 2017 Gavin NR, Satin AJ. Simulation Training in Obstetrics. Clin Obstet Gynecol. 2017;60(4):802-810. doi:10.1097/GRF.0000000000000322. https://psnet.ahrq.gov/issue/simulation-training-obstetrics Adverse events in obstetrics put both maternal and infant patients at ris…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42291/psn-pdf
    September 12, 2016 - Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. September 12, 2016 Acquaviva K, Haskell H, Johnson J. Human cognition and the dynamics of failure to rescue: the Lewis Blackman case. J Prof Nurs. 2013;29(2):95-101. doi:10.1016/j.profnurs.2012.12.009. https://psnet.ahrq.gov/issue/huma…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38165/psn-pdf
    January 31, 2011 - Patient care, square-rigger sailing, and safety. January 31, 2011 Henkind SJ, Sinnett C. Patient care, square-rigger sailing, and safety. JAMA. 2008;300(14):1691-3. doi:10.1001/jama.300.14.1691. https://psnet.ahrq.gov/issue/patient-care-square-rigger-sailing-and-safety To maximize safety, information handoff and s…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39384/psn-pdf
    March 24, 2010 - Keeping safety a priority in home care and hospice: one agency's journey. March 24, 2010 Mullin LV. Keeping safety a priority in home care and hospice: one agency's journey. Home Healthc Nurse. 2010;28(2):63-70. doi:10.1097/NHH.0b013e3181cb5939. https://psnet.ahrq.gov/issue/keeping-safety-priority-home-care-and-ho…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41834/psn-pdf
    November 14, 2012 - Implementing AORN recommended practices for transfer of patient care information. November 14, 2012 Seifert PC. Implementing AORN recommended practices for transfer of patient care information. AORN J. 2012;96(5):475-93. doi:10.1016/j.aorn.2012.08.011. https://psnet.ahrq.gov/issue/implementing-aorn-recommended-pra…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37014/psn-pdf
    September 15, 2011 - Medication safety messages for patients via the web portal: the MedCheck intervention. September 15, 2011 Weingart SN, Hamrick HE, Tutkus S, et al. Medication safety messages for patients via the web portal: the MedCheck intervention. Int J Med Inform . 2008;77(3):161-168. https://psnet.ahrq.gov/issue/medication-s…

  15. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Elizabeth Gould, NP-C, COR…

  16. Perils in Diagnosing a Stroke | PSNet

    psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
    August 15, 2017 - Perils in Diagnosing a Stroke Citation Text: Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  17. CVC Placement: Speak Now or Do Not Use the Line | PSNet

    psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
    November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line Citation Text: Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836841/psn-pdf
    June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission April 7, 2022 https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and- paramedics-provide-home Sum…

  19. Spotlight (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
    January 01, 2019 - Spotlight Spotlight Mistaken Attribution, Diagnostic Misstep * Source and Credits This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33643/psn-pdf
    December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA December 1, 2006 In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and Critic…
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