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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49639/psn-pdfNovember 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33738/psn-pdfDecember 01, 2012 - In Conversation With... John G. Reiling, PhD December 1, 2012 In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with hospitals and… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/853773/psn-pdfSeptember 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49663/psn-pdfSeptember 01, 2012 - Peripheral IV in Too Long September 1, 2012 Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long Case Objectives Appreciate the complications associated with peripheral intravenous (IV) catheters. Describe the optimal sterile technique that should be us… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33885/psn-pdfAugust 01, 2019 - In Conversation With… Susan Smith, MD August 1, 2019 In Conversation With… Susan Smith, MD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-smith-md Editor's note: Dr. Smith, a family medicine physician, is chief faculty practices officer for UCSF Health. Over the past 3–4 years, the … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49552/psn-pdfJanuary 01, 2008 - How Do Providers Recover From Errors? January 1, 2008 West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors Case Objectives Describe the provider-specific prevalence of medical errors. Appreciate the impact of medical errors on care pr… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33663/psn-pdfSeptember 15, 2008 - Implementing a Patient Safety Program at a Large National Health System January 1, 2008 Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system Perspectiv… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33841/psn-pdfSeptember 01, 2017 - In Conversation With… Andrew Gettinger, MD September 1, 2017 In Conversation With… Andrew Gettinger, MD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md Editor's note: Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the Office of Cli… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33746/psn-pdfMarch 01, 2013 - In Conversation With… David M. Gaba, MD March 1, 2013 In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of Medicine. An international leade… -
Spotlight (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.pptJanuary 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 … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49799/psn-pdfJuly 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33696/psn-pdfJune 01, 2010 - In Conversation with…Pat Croskerry, MD, PhD June 1, 2010 In Conversation with…Pat Croskerry, MD, PhD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd Editor's note: Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in Halifax, Nova… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33704/psn-pdfDecember 01, 2010 - In Conversation with...Geri Amori, PhD December 1, 2010 In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd Editor's note: Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and Patient Safety Institute, a… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49642/psn-pdfDecember 01, 2011 - Order Interrupted by Text: Multitasking Mishap December 1, 2011 Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap Case Objectives State the prevalence of mobile devices among clinicians and their common health… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49543/psn-pdfSeptember 01, 2007 - Medication Reconciliation: Whose Job Is It? September 1, 2007 Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it Case Objectives Appreciate the prevalence and impact of medication discrepancies at times of transition in … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49699/psn-pdfFebruary 01, 2014 - Multifactorial Medication Mishap February 1, 2014 Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Id… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49606/psn-pdfAugust 01, 2010 - Weighing In on Surgical Safety August 1, 2010 Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/weighing-surgical-safety Case Objectives Identify the comorbidites associated with obesity that place patients at higher risk for surgical complications. Un… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60172/psn-pdfMarch 01, 2021 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart Originally published on June 12, 2020 Last updated on January 11, 2021 https://psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly- reduc… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49573/psn-pdfJanuary 01, 2009 - Dangerous Shift November 1, 2008 Patterson ES. Dangerous Shift. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dangerous-shift Case Objectives Review the evidence base on erroneous actions related to shift changes. Understand the limits of standardizing handoffs in preventing errors at shift change. Expla… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33723/psn-pdfDecember 01, 2011 - Implementing a Fall Prevention Program December 1, 2011 Healey F. Implementing a Fall Prevention Program. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/implementing-fall-prevention-program Perspective Throughout the developed world, most hospital beds are occupied by older people, many of whom have b…
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