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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49587/psn-pdf
    May 01, 2009 - Missing Trauma May 1, 2009 Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/missing-trauma The Case A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a few minutes later by a customer, who immediately called 911. On arrival, para…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49700/psn-pdf
    February 01, 2014 - Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients February 1, 2014 Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/nonsustaine…
  3. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
    March 01, 2011 - Spotlight Case July 2008 Spotlight Case March 2011 Volume Too Low: In and Out Pediatric Patient Safety * * Source and Credits This presentation is based on the March 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Marlene Miller, MD, MSc…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49850/psn-pdf
    January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia January 1, 2019 Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia The Case A 72-year-old woman with a history of severe peripheral vascular dis…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49757/psn-pdf
    April 01, 2016 - Situational Awareness and Patient Safety April 1, 2016 Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety The Case A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…
  6. psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
    January 31, 2020 - Annual Perspective Patient Safety in Medical, Nursing, and Other Clinical Education March 16, 2020  View more articles from the same authors. Citation Text: Howley LD, Hall KK, Fitall E. Patient Safety in Medical, Nursing, and Other Clinical Education . PSNe…
  7. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.281_slideshow.ppt
    October 01, 2012 - Spotlight Case July 2008 Spotlight Case CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure * * Source and Credits This presentation is based on the October 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Catherine L…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73434/psn-pdf
    June 30, 2021 - The Consequences of Miscommunication Regarding a Possible Artifact June 30, 2021 Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact Disclosure of Relevant Financial Relationships…
  9. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
    January 01, 2021 - Spotlight Spotlight Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough Source and Credits • This presentation is based on the April 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Verna Gibbs, MD o AHRQ W…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49552/psn-pdf
    January 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…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49857/psn-pdf
    March 01, 2019 - Duplicate Insulin Order March 1, 2019 Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/duplicate-insulin-order The Case A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency department (ED) for complaints of letharg…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…
  14. psnet.ahrq.gov/primer/failure-rescue
    September 15, 2024 - Failure to Rescue Citation Text: Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…
  15. psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
    May 11, 2019 - SPOTLIGHT CASE The Consequences of Miscommunication Regarding a Possible Artifact Citation Text: Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
  16. psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
    May 22, 2024 - SPOTLIGHT CASE How Do Providers Recover From Errors? Citation Text: West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar Bi…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836839/psn-pdf
    March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare Staff March 31, 2022 Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff Introduction The…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841467/psn-pdf
    December 14, 2022 - A framework for assessing reasoning about controversial end-of-life clinical decisions. December 14, 2022 Fedyk M, Fairman N, Romano PS, et al. A framework for assessing reasoning about controversial end-of- life clinical decisions. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/framework-assessing-reasonin…
  19. psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - The Role of Undergraduate Nursing Education in Patient Safety Joan Stanley, PhD, NP, FAAN, FAANP; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD | November 27, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Stanley J, Ga…
  20. psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety Joan Stanley, PhD, NP, FAAN, FAANP | November 27, 2023  Also Read the Essay View more articles from the same authors. Citation Text: Stanley J. In Conversat…

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