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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854897/psn-pdf
    October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose October 31, 2023 Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/weight-and-…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846563/psn-pdf
    March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March 2022 conviction of RaDonda Vaught, a former nu…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49570/psn-pdf
    October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure? October 1, 2008 Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure Case Objectives Understand the complementary abilities of an electronic health record a…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72811/psn-pdf
    September 01, 2022 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Originally published on March 3, 2021 Last updated on March 16, 2021 https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during- initial-treatment Summar…

  5. Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx Spotlight Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the ful…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49633/psn-pdf
    September 01, 2011 - The Safety and Quality of Long Term Care September 1, 2011 Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care Case Objectives Identify commonly reported adverse events in long-term care. Identify two to three challenges…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49482/psn-pdf
    May 01, 2005 - Pregnant With Danger May 1, 2005 Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pregnant-danger The Case A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of the night complaining of left leg pain. She also had so…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33744/psn-pdf
    February 01, 2013 - In Conversation With… Beverley H. Johnson February 1, 2013 In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient- and Family-…

  9. Complaints as Safety Surveillance | PSNet

    psnet.ahrq.gov/web-mm/complaints-safety-surveillance
    May 05, 2021 - Complaints as Safety Surveillance Citation Text: Morris JL, Bismark M. Complaints as Safety Surveillance. 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 E…

  10. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose | PSNet

    psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
    March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose Citation Text: Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

  11. Impact of System Failures on Healthcare Workers | PSNet

    psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
    August 30, 2023 - Annual Perspective Impact of System Failures on Healthcare Workers George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD | March 21, 2023  View more articles from the same authors. Citation Text: Zangaro G, Van CM, Mossburg S. Imp…

  12. When the Indications for Drug Administration Blur | PSNet

    psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
    May 26, 2021 - SPOTLIGHT CASE When the Indications for Drug Administration Blur Citation Text: Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation …

  13. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists | PSNet

    psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
    February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists Citation Text: Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…

  14. Right? Left? Neither! | PSNet

    psnet.ahrq.gov/web-mm/right-left-neither
    November 16, 2022 - SPOTLIGHT CASE Right? Left? Neither! Citation Text: Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837627/psn-pdf
    July 06, 2022 - Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity. July 6, 2022 Howell EA, Sofaer S, Balbierz A, et al. Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity. Obstet Gynecol. …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851053/psn-pdf
    June 28, 2023 - In situ simulation as a quality improvement tool to identify and mitigate latent safety threats for emergency department SARS-CoV-2 airway management: a multi- institutional initiative. June 28, 2023 Yang CJ, Saggar V, Seneviratne N, et al. In situ simulation as a quality improvement tool to identify and mitigate…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47876/psn-pdf
    March 27, 2019 - Evaluation of medication errors at the transition of care from an ICU to non-ICU location. March 27, 2019 Tully AP, Hammond DA, Li C, et al. Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location. Crit Care Med. 2019;47(4):543-549. doi:10.1097/CCM.0000000000003633. https://psnet.…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46155/psn-pdf
    December 21, 2017 - A national implementation project to prevent catheter- associated urinary tract infection in nursing home residents. December 21, 2017 Mody L, Greene T, Meddings J, et al. A National Implementation Project to Prevent Catheter-Associated Urinary Tract Infection in Nursing Home Residents. JAMA Intern Med. 2017;177(8…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42566/psn-pdf
    September 11, 2013 - Using a patient internet portal to prevent adverse drug events: a randomized, controlled trial. September 11, 2013 Weingart SN, Carbo AR, Tess A, et al. Using a Patient Internet Portal to Prevent Adverse Drug Events. J Patient Saf. 2013;9(3). doi:10.1097/pts.0b013e31829e4b95. https://psnet.ahrq.gov/issue/using-pat…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43262/psn-pdf
    April 06, 2015 - Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. April 6, 2015 Johnston MJ, Arora S, Anderson O, et al. Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. Ann Surg. 2015;261(5):831-838. doi:…
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