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9641. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/74277
      January 01, 2021 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Medication/Drug Errors Curated Library Primers Medication Administration Errors Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March, 12 2021 Medication administration errors are a persistent patient saf…

9642. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72586/psn-pdf
      December 23, 2020 - Code Status vs. Care Status December 23, 2020 Krisman RK, Spero H. Code Status vs. Care Status. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/code-status-vs-care-status Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical Education (AC…

9643. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60241/psn-pdf
      February 24, 2022 - Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes February 24, 2022 Bakerjian D. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-…

9644. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866216/psn-pdf
      July 10, 2024 - Health Plan Patient Safety Initiatives July 10, 2024 Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives When we think of improving patient safety, we often think of strategies that can be implemen…

9645. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860015/psn-pdf
      September 01, 2024 - Retained Surgical Items: Definition and Epidemiology. January 4, 2024 Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology. PSNet [internet]. 2024. https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology Background Prudent medical practice and federal and state laws r…

9646. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852699/psn-pdf
      August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety August 30, 2023 Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety The COVID-19 pandemic necessitated a shift in operations …

9647. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33711/psn-pdf
      May 01, 2011 - The Second Victim Phenomenon: A Harsh Reality of Health Care Professions May 1, 2011 Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions Perspective The Instit…

9648. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
      June 01, 2015 - PowerPoint Presentation Spotlight Anchoring Bias With Critical Implications 1 This presentation is based on the June 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Edward Etchells, MD, MSc, Division of General Internal Medicine, Centre for Q…

9649. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33733/psn-pdf
      July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes July 1, 2012 Koppel R. Patient Safety and Health Information Technology: Learning from Our Mistakes. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes Perspe…

9650. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60330/psn-pdf
      May 05, 2020 - Telehealth and Patient Safety During the COVID-19 Response May 14, 2020 Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response Introduction   Telehealth typ…

9651. Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling | PSNet
      psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
      June 28, 2023 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January 31, 2024 Innovation Contact …

9652. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850678/psn-pdf
      June 14, 2023 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration June 14, 2023 https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults- risk-hospital Summary To address a well-documented hospital adverse outco…

9653. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
      January 01, 2024 - Spotlight Spotlight Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary …

9654. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33645/psn-pdf
      February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? February 1, 2007 Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common Perspectiv…

9655. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50769/psn-pdf
      February 15, 2017 - Cultural Competence and Patient Safety December 27, 2019 Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety Background   Culture can be defined as the “personal identification, language, thoughts, co…

9656. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
      June 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case June 2007 Beeline to Spine Source and Credits This presentation is based on June 2007 AHRQ WebM&M Spotlight Case See full article at http://webmm.ahrq.gov CME credit is available online Commentary by: Gerald W. Smetana, MD, Harvard Medical School, Beth Israel D…

9657. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33662/psn-pdf
      January 01, 2008 - In Conversation with…Jennifer Daley, MD January 1, 2008 In Conversation with…Jennifer Daley, MD. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md Editor's note: Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the organization for …

9658. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60173/psn-pdf
      March 30, 2020 - In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD March 30, 2020 In Conversation With.. Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md Editor’s note: Ann D. Gaffey, RN, …

9659. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33743/psn-pdf
      December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit December 1, 2012 Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit. PSNet [internet]. 2012. https://psnet.ahrq.gov…

9660. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33614/psn-pdf
      June 01, 2005 - Interpreting the Patient Safety Literature June 1, 2005 Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature Perspective Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…