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psnet.ahrq.gov/issue/putting-safety-curriculum
February 10, 2010 - Newspaper/Magazine Article
Putting safety on the curriculum.
Citation Text:
Ellis O. Putting safety on the curriculum. BMJ (Clinical research ed.). 2009;339:b3725. doi:10.1136/bmj.b3725.
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psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
April 28, 2021 - Procedural Mishap: Learning Curve?
Citation Text:
Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - Medical Devices in the "Wild"
December 1, 2014
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medical-devices-wild
The Case
A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes,
chronic pain, arthritis, and…
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psnet.ahrq.gov/web-mm/bowel-prep
March 01, 2017 - Bowel Prep
Citation Text:
Nelson D. Bowel Prep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downloa…
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - Refused Medication Error
Citation Text:
Foley M. Refused Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49776/psn-pdf
November 01, 2016 - Continuity Errors in Resident Clinic
November 1, 2016
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
The Case
A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty
concentrating. …
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - A Seasonal Care Transition Failure
July 1, 2011
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
The Case
A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine
resident—for routine follow-up…
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psnet.ahrq.gov/node/49719/psn-pdf
September 01, 2014 - No BP During NIBP
September 1, 2014
Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/no-bp-during-nibp
The Case
An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization
laboratory under general endotracheal anes…
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - Dangerous Dapsone
Citation Text:
Bookwalter T. Dangerous Dapsone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - SPOTLIGHT CASE
Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery
Citation Text:
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading
to Multiple Complications and Operations
September 25, 2024
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications
and Operations. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - Fourth, engaging patients and families in discharge planning throughout the hospital stay.
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psnet.ahrq.gov/periodic-issue/periodic-issue-297
June 30, 2021 - June 23, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - SPOTLIGHT CASE
Physical Diagnosis: A Lost Art?
Citation Text:
Thompson GR, Verghese A. Physical Diagnosis: A Lost Art?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx
Spotlight
Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm…
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psnet.ahrq.gov/issue/evaluation-healthcare-safety-climate-measurement-tool
August 08, 2018 - Study
Evaluation of a healthcare safety climate measurement tool.
Citation Text:
Turnberg W, Daniell W. Evaluation of a healthcare safety climate measurement tool. J Safety Res. 2008;39(6):563-8. doi:10.1016/j.jsr.2008.09.004.
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psnet.ahrq.gov/issue/process-analysis-sentinel-events-due-health-care-associated-infection
January 22, 2014 - Commentary
A process for analysis of sentinel events due to health care–associated infection.
Citation Text:
Carrico R, Ramírez J. A process for analysis of sentinel events due to health care-associated infection. Am J Infect Control. 2007;35(8):501-7.
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psnet.ahrq.gov/issue/cultural-transformation-toward-patient-safety-one-conversation-time
November 16, 2022 - Commentary
Cultural transformation toward patient safety: one conversation at a time.
Citation Text:
Moore ML, Putman PA. Cultural transformation toward patient safety: one conversation at a time. Nurs Admin Q. 2008;32(2):102-108. doi:10.1097/01.NAQ.0000314538.36865.09.
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psnet.ahrq.gov/periodic-issue/periodic-issue-466
December 18, 2024 - December 4, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
Citation Text:
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…