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  1. The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications | PSNet

    psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
    July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications Save Save to your library Print Download PDF Sha…

  2. Missed Opportunities for Suicide Risk Assessment | PSNet

    psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
    September 27, 2023 - SPOTLIGHT CASE Missed Opportunities for Suicide Risk Assessment Citation Text: Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation For…

  3. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
    January 29, 2021 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery Citation Text: Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…

  4. The Impact of Communication on Medication Errors | PSNet

    psnet.ahrq.gov/web-mm/impact-communication-medication-errors
    August 01, 2009 - The Impact of Communication on Medication Errors Citation Text: Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: …

  5. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case | PSNet

    psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
    October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case Citation Text: Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …

  6. Rediscovering the Power of the Surgical M&M Conference: The M M Matrix | PSNet

    psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
    September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix Leo A. Gordon, MD | September 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The…

  7. Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective | PSNet

    psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
    June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective Zahra Khudeira, PharmD | June 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Khudeira Z. Becoming a Certified Professional in Patient Safet…

  8. Human Factors Engineering Can Teach You How to Be Surprised Again | PSNet

    psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
    November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again John Gosbee, MD, MS | November 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Aga…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850673/psn-pdf
    June 14, 2023 - In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm June 14, 2023 Johnson B. In Conversation with.. Beverley H. Johnson about The Role of Patient's Family In Reducing Harm. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-r…

  10. Interpreting the Patient Safety Literature | PSNet

    psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
    June 01, 2005 - Interpreting the Patient Safety Literature Kaveh G. Shojania, MD | June 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. Rockville (MD): Agency f…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853774/psn-pdf
    September 27, 2023 - Delayed Evaluation of Abdominal Pain in an Elderly Patient. September 27, 2023 Klimkiv L, Utter GH, Barnes DK. Delayed Evaluation of Abdominal Pain in an Elderly Patient. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient The Case An 85-year-old woman presente…

  12. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. | PSNet

    psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
    October 31, 2023 - SPOTLIGHT CASE Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. Citation Text: Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…

  13. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? | PSNet

    psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
    September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? Ashish K. Jha, MD, MPH | September 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Jha AK. What Can the Rest of the Heal…

  14. The Safety of Medical Devices | PSNet

    psnet.ahrq.gov/perspective/safety-medical-devices
    June 01, 2011 - The Safety of Medical Devices Christopher Nemeth, PhD | June 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…

  15. 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…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837913/psn-pdf
    August 31, 2022 - Miscommunication During the Interhospital Transport of a Critically Ill Child August 31, 2022 Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-c…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865655/psn-pdf
    April 24, 2024 - Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. April 24, 2024 Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-comp…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/864867/psn-pdf
    April 10, 2024 - Hindsight is 20/20: Thrombolytics for Alcohol Intoxication April 10, 2024 Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication Disclosure of Relevant Financial Relationships: As a provider accredited by th…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74830/psn-pdf
    June 01, 2022 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications February 23, 2022 https://psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-co…

  20. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression | PSNet

    psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
    May 26, 2021 - SPOTLIGHT CASE Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression Citation Text: Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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