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4761. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40335/psn-pdf
      December 18, 2014 - Assessing teamwork and communication in the authentic patient care learning environment. December 18, 2014 Haftel HM, Hicks PJ. Assessing teamwork and communication in the authentic patient care learning environment. Pediatrics. 2011;127(4):601-3. doi:10.1542/peds.2010-3767. https://psnet.ahrq.gov/issue/assessing-…

4762. Toolkits | PSNet
      psnet.ahrq.gov/toolkits
      March 01, 2025 - Toolkits Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols. Want to submit a Toolkit? Has your organization deve…

4763. Slow Down: Right Drug, Wrong Formulation | PSNet
      psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
      October 13, 2018 - Slow Down: Right Drug, Wrong Formulation Citation Text: Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndN…

4764. Failure to Rescue | PSNet
      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…

4765. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49663/psn-pdf
      September 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…

4766. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60745/psn-pdf
      October 01, 2020 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia July 29, 2020 Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involvi…

4767. Handoffs and Transitions | PSNet
      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…

4768. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49592/psn-pdf
      October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

4769. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33695/psn-pdf
      April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance April 1, 2010 Roberts LL, Ward MM, Evans TC. The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance. PSNet [internet]. 2010. ht…

4770. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33666/psn-pdf
      October 01, 2008 - Methicillin-Resistant Staphylococcus aureus April 1, 2008 Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus Perspective Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …

4771. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33884/psn-pdf
      July 01, 2019 - Emerging Safety Issues in Artificial Intelligence July 1, 2019 Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence Perspective Background Since the beginning of digital health records, there has bee…

4772. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33682/psn-pdf
      April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH April 1, 2009 In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph Editor's note: Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent s…

4773. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49739/psn-pdf
      August 21, 2015 - Breathe Easy: Safe Tracheostomy Management August 21, 2015 Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management The Case A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…

4774. Is the "Surgical Personality" a Threat to Patient Safety? | PSNet
      psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
      February 24, 2021 - April 4, 2011 Explaining Michigan: developing an ex post theory of a quality improvement

4775. Managing Ascites: Hazards of Fluid Removal | PSNet
      psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
      June 01, 2018 - This is because the risk of developing acute kidney injury and/or hepatorenal syndrome is highest in

4776. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36860/psn-pdf
      January 20, 2016 - IHI Global Trigger Tool for Measuring Adverse Events. 2nd Edition. January 20, 2016 Griffin FA, Resar RK. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009. https://psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events-2nd-edition This white paper describ…

4777. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36778/psn-pdf
      August 26, 2011 - What medications does your patient take? Enhancing medication safety in the outpatient setting. August 26, 2011 Institute for Healthcare Improvement; IHI https://psnet.ahrq.gov/issue/what-medications-does-your-patient-take-enhancing-medication-safety- outpatient-setting This article discusses the importance of me…

4778. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35029/psn-pdf
      January 05, 2017 - Creating an integrated patient safety team. January 5, 2017 Gandhi TK, Graydon-Baker E, Barnes JN, et al. Creating an integrated patient safety team. Jt Comm J Qual Saf. 2003;29(8):383-90. https://psnet.ahrq.gov/issue/creating-integrated-patient-safety-team Drawing from their experiences at Brigham and Women’s Hos…

4779. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34972/psn-pdf
      May 11, 2017 - 2017 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals. May 11, 2017 Horsham, PA: Institute for Safe Medication Practices; March 2017. https://psnet.ahrq.gov/issue/2017-ismp-medication-safety-self-assessmentr-antithrombotic-therapy- hospitals This tool provides institutions with the …

4780. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39141/psn-pdf
      June 27, 2011 - Determination of health-care teamwork training competencies: a Delphi study. June 27, 2011 Clay-Williams R, Braithwaite J. Determination of health-care teamwork training competencies: a Delphi study. Int J Qual Health Care. 2009;21(6):433-40. doi:10.1093/intqhc/mzp042. https://psnet.ahrq.gov/issue/determination-he…