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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - SPOTLIGHT CASE
Medication Reconciliation: Whose Job Is It?
Citation Text:
Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - Nursing and Patient Safety
April 21, 2021
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/nursing-and-patient-safety
Updated in March 2021. Originally published in December 2011 by researchers at the University of
California, San Francisco. …
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
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psnet.ahrq.gov/node/49825/psn-pdf
April 01, 2018 - When Patients and Providers Speak Different Languages
April 1, 2018
Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
Case Objectives
Understand the legal and regulatory obligations to prov…
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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/node/49527/psn-pdf
December 01, 2006 - Right Patient, Wrong Sample
December 1, 2006
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
The Case
A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On
the morning of surgery, the patien…
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
Editor's note: The topic of patient safety in long-term care facilities has not received the attent…
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psnet.ahrq.gov/node/49708/psn-pdf
May 01, 2014 - Medication Reconciliation With a Twist (or Dare We Say, a
Patch?)
May 1, 2014
Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
Case Objectives
Appreciate that medication discrepanc…
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psnet.ahrq.gov/primer/simulation-training
September 15, 2024 - Simulation Training
Citation Text:
Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - SPOTLIGHT CASE
Near Miss with Bedside Medications
Citation Text:
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - Nursing and Patient Safety
Citation Text:
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Format:
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psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
Citation Text:
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.In Conversation with...Patrick S. Romano, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/node/33616/psn-pdf
August 01, 2005 - The Unfinished Patient Safety Agenda
August 1, 2005
Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
Perspective
The goal set by the Institute of Medicine (IOM) in 1999 to reduce medical errors by half within 5 years has
no…
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psnet.ahrq.gov/node/33574/psn-pdf
March 15, 2025 - Ambulatory Care Safety
March 15, 2025
Ambulatory Care Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/ambulatory-care-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Las…
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psnet.ahrq.gov/primer/culture-safety
September 15, 2024 - Culture of Safety
Citation Text:
Culture of Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/node/33577/psn-pdf
September 15, 2024 - Duty Hours and Patient Safety
September 15, 2024
Duty Hours and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/duty-hours-and-patient-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the …
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - Accreditation and Regulation: Can They Help Improve Patient Safety?
Rebecca N. Warburton, PhD | April 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Warburton RN. Accreditation and Regulation: Can They Help Improve Pat…
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psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
December 27, 2019 - Cultural Competence and Patient Safety
December 27, 2019
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
April 01, 2013 - In Conversation With… Christopher P. Landrigan, MD, MPH
April 1, 2013
Also Read an Essay
Citation Text:
In Conversation With… Christopher P. Landrigan, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …