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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Annual Perspective
Handoffs and Transitions
Niraj Sehgal, MD, MPH | January 22, 2014
View more articles from the same authors.
Citation Text:
Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room
Citation Text:
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…
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psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment
Citation Text:
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
…
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psnet.ahrq.gov/perspective/workplace-safety-health-care
January 01, 2017 - Workplace Safety in Health Care
Ross W. Simon and Elena G. Canacari, RN | January 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Simon RW, Canacari EG. Workplace Safety in Health Care. PSNet [internet]. Rockville (MD):…
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psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
April 01, 2013 - In Conversation With… Christopher P. Landrigan, MD, MPH
April 1, 2013
Also Read an Essay
Citation Text:
In Conversation With… Christopher P. Landrigan, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
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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/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - Spotlight
Spotlight
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
1
Source and Credits
This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: David…
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psnet.ahrq.gov/node/866993/psn-pdf
October 30, 2024 - It sounds like you're doing a lot of work to decrease barriers for
patients to access services and care
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psnet.ahrq.gov/node/865373/psn-pdf
March 27, 2024 - But if there is a decrease in pain, there is a potential for improved ambulation and faster
recovery
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - whether or not further testing for PE is indicated
• The PE Rule-out Criteria (PERC), developed to decrease
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - PSYCH: A mnemonic to help psychiatric residents decrease patient handoff communication errors.
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - ratios (ie, class-size initiatives)
Aiken, 2002 ( 2 )
California legislation; other pressure
Decrease
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psnet.ahrq.gov/node/60611/psn-pdf
June 24, 2020 - If done well, order sets can decrease cognitive
burden, prevent errors and minimize the time involved
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psnet.ahrq.gov/node/838222/psn-pdf
September 28, 2022 - We are always thinking about how to
ensure that anything we do for patients may help them and decrease
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - HAIs [healthcare associated infections], then there should be future
data to track the increase or decrease
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psnet.ahrq.gov/node/33750/psn-pdf
May 01, 2013 - issue/improving-patient-safety-intensive-care-units-michigan
https://psnet.ahrq.gov/issue/intervention-decrease-catheter-related-bloodstream-infections-icu
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psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
March 01, 2015 - hospitals with similarly elevated HSMRs escaped attention.( 13 ) In addition, most of the subsequent decrease
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - hospitals with similarly elevated HSMRs escaped attention.( 13 ) In addition, most of the subsequent decrease
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psnet.ahrq.gov/node/861838/psn-pdf
January 31, 2024 - Adverse Drug Event (ADE) Surveillance and Pharmacist
Counseling
January 31, 2024
https://psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
Summary
Adverse events resulting from medications are a common occurrence that often go undetected, unreported,
and unaddressed.1 The imp…