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9521. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857059/psn-pdf
      November 29, 2023 - The Risks of a Malpositioned Gastrostomy Tube and Poor Communication November 29, 2023 Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication Disclosure of Relevant Financial …

9522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60174/psn-pdf
      March 30, 2020 - Making Healthcare Safer III Report March 30, 2020 Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report What is the Making Healthcare Safer Report? The Making Healthcare Safer Report represents an ef…

9523. The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis | PSNet
      psnet.ahrq.gov/innovation/generalizability-medication-administration-discrepancy-detection-system-quantitative
      November 04, 2020 - EMERGING INNOVATIONS The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis Citation Text: Kirkendall E, Huth H, Rauenbuehler B, et al. The generalizability of a medication administration discrepancy detection system: quantitative compar…

9524. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
      November 01, 2011 - Spotlight Case July 2008 Spotlight Case Near Miss with Bedside Medications * * Source and Credits This presentation is based on the November 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Albert W. Wu, MD, MPH, Johns Hopkins Bloomberg S…

9525. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33671/psn-pdf
      July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis July 1, 2008 Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis Perspective Throughout most of his life, …

9526. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33836/psn-pdf
      June 01, 2017 - The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed? June 1, 2017 Martin VK, Mirnateghi N, Khoshchehreh M. The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed? . PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed Per…

9527. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.104_slideshow.ppt
      September 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case September 2005 Double Trouble Source and Credits This presentation is based on the Sept. 2005 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Jerry H. Gurwitz, MD, University of…

9528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33569/psn-pdf
      June 15, 2024 - Readmissions and Adverse Events After Discharge June 15, 2024 Readmissions and Adverse Events After Discharge. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that t…

9529. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33563/psn-pdf
      September 16, 2024 - Culture of Safety September 16, 2024 Culture of Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/culture-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in …

9530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60744/psn-pdf
      July 29, 2020 - The NSTEMI Curbside Consultation July 29, 2020 Villablanca AC, Wong GX. The NSTEMI Curbside Consultation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/nstemi-curbside-consultation Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical E…

9531. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
      January 01, 2024 - Spotlight Spotlight Do Not Miss Sepsis Needles in Viral Haystacks! Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Michelle Hamline, MD, PhD, MAS and Ulfat Shaikh, MD, M…

9532. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60362/psn-pdf
      April 13, 2018 - Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area June 12, 2020 https://psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes- high-risk Summary Formerly known as the Antenatal and Neonatal Guidelines, Education…

9533. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852698/psn-pdf
      August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation August 30, 2023 https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and- diagnostic-accuracy Summary Addressing diagnostic errors to improve outcomes and patient safety h…

9534. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49522/psn-pdf
      November 01, 2006 - Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality November 1, 2006 Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…

9535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50611/psn-pdf
      October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing October 30, 2019 Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing Case Objectives List the most common errors associated with computerized…

9536. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49546/psn-pdf
      October 17, 2007 - Do Not Disturb! October 1, 2007 Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/do-not-disturb Case Objectives Define professionalism. Discuss behaviors associated with lack of professionalism. Outline steps one should take if a significant breach of professionalism is …

9537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/854849/psn-pdf
      October 31, 2023 - “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records October 31, 2023 MacDonald S. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record Th…

9538. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49519/psn-pdf
      September 01, 2006 - Triple Handoff September 1, 2006 Vidyarthi A. Triple Handoff. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/triple-handoff Case Objectives Appreciate the prevalence of handoffs and sign out related errors. Understand the key elements of a safe and effective written and verbal sign out. List Kotter’s 8 st…

9539. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49690/psn-pdf
      September 01, 2013 - The Pains of Chronic Opioid Usage September 1, 2013 Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage Case Objectives Describe the appropriate initial assessment of patients with chronic non-cancer pain. List the most comm…

9540. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49651/psn-pdf
      May 01, 2012 - The Perils of Cross Coverage May 1, 2012 Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/perils-cross-coverage Case Objectives Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and care transitions. Describe ed…