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psnet.ahrq.gov/node/49560/psn-pdf
April 01, 2008 - include taking steps to ensure that the goals of care are
communicated across settings of care and considering
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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - In considering how best to perform emergent airway
management in this setting, the physician should
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psnet.ahrq.gov/node/49596/psn-pdf
December 01, 2009 - This patient's experience illustrates several key points for those considering or advising others about
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psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - In
considering this question, it is important to recognize that it is essential that physicians in training
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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - an opportunity to harness the environment as a tool to improve both patient and caregiver safety by considering
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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - The NICE guideline provides the most specific recommendations related to FMS.( 9 ) Before considering
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psnet.ahrq.gov/node/33661/psn-pdf
December 01, 2007 - record and requires that they be completed within 30 days
of discharge.(8) This is far too permissive, considering
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psnet.ahrq.gov/web-mm/or-peeping
May 01, 2015 - Although most people think of names or social security numbers when considering PHI, HIPAA regulations
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - leadership, focusing on stronger corrective actions, measuring implementation and impact on outcomes, and considering
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psnet.ahrq.gov/node/42099/psn-pdf
March 13, 2013 - Inpatient fall prevention programs as a patient safety
strategy: a systematic review.
March 13, 2013
Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a
systematic review. Ann Intern Med. 2013;158(5 Pt 2):390-396. doi:10.7326/0003-4819-158-5-201303051-
00005.
…
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psnet.ahrq.gov/node/73902/psn-pdf
September 29, 2021 - Dangers of Missing an Epidural Abscess: Multiple Visits
and Delayed Diagnosis with a Severely Negative Outcome
September 29, 2021
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed
Diagnosis with a Severely Negative Outcome. PSNet [internet]. 2021.
https://psnet.ahrq.go…
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psnet.ahrq.gov/issue/problem-checklists
March 29, 2023 - Commentary
The problem with checklists.
Citation Text:
Catchpole K, Russ S. The problem with checklists. BMJ Qual Saf. 2015;24(9):545-9. doi:10.1136/bmjqs-2015-004431.
Copy Citation
Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking
January 26, 2022
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Disclosure of Relevant Financial Relationships: As a provider ac…
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Double Dosing, by the Rules
March 21, 2009
Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/double-dosing-rules
The Case
A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was
admitted to a medical unit during the night with wo…
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psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
March 12, 2021 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport
Citation Text:
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…
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psnet.ahrq.gov/node/42083/psn-pdf
March 13, 2013 - The top patient safety strategies that can be encouraged
for adoption now.
March 13, 2013
Shekelle PG, Pronovost P, Wachter R, et al. The top patient safety strategies that can be encouraged for
adoption now. Ann Intern Med. 2013;158(5 Pt 2):365-8. doi:10.7326/0003-4819-158-5-201303051-00001.
https://psnet.ahrq.go…
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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…
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - The presence of these reports in specialty journals is not surprising, considering more HIV/AIDS patients
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psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading
to Multiple Complications and Operations
September 25, 2024
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications
and Operations. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.2_slideshow.ppt
February 01, 2003 - PowerPoint Presentation
Spotlight Case February 2003
Apnea in a Patient Under General Anesthesia
webmm.ahrq.gov
Source and Credits
This presentation is based on February 2003 Surgery–Anesthesia Spotlight Case
See full case–commentary on webmm.ahrq.gov
CME credit is available online
Commentary by: Paul Barach,…