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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safetyOctober 01, 2009 - It had to do with the fact that the ACGME [Accreditation Council for Graduate Medical Education], which … is the certifying arm for physician training programs, took steps to remove the accreditation for the … surgery training program at the hospital because it had more residents than it was allowed. … program, but this demonstrated some of the serious problems that existed in the hospital. … program.
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psnet.ahrq.gov/perspective/conversation-charles-ornsteinOctober 01, 2009 - It had to do with the fact that the ACGME [Accreditation Council for Graduate Medical Education], which … is the certifying arm for physician training programs, took steps to remove the accreditation for the … surgery training program at the hospital because it had more residents than it was allowed. … program, but this demonstrated some of the serious problems that existed in the hospital. … program.
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptxJanuary 01, 2024 - and Ulfat Shaikh, MD Managing Editor: Meghan Weyrich, MPH 2 Objectives At the conclusion of this educational … activity, participants should be able to: Describe the risk factors for intraoperative awareness.
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/60746/psn-pdfJuly 29, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy July 29, 2020 Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy The Case A 28-year-old woman arrived at the Emergency Department (ED) complaining o… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49854/psn-pdfFebruary 01, 2019 - Diagnostic Failure: The Growing Deficit February 1, 2019 Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit The Case A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33694/psn-pdfApril 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010 In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a priva… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33658/psn-pdfOctober 01, 2007 - In Conversation with...David Marx, JD October 1, 2007 In Conversation with..David Marx, JD. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd Editor's Note: An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49572/psn-pdfOctober 01, 2008 - Mistaken Identity October 1, 2008 Hall LW. Mistaken Identity. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/mistaken-identity The Case An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status and a reported fall. After finding tenderness in her left hip, the p… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865570/psn-pdfApril 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner April 10, 2024 https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive- approach-data Summary North American Partners… -
psnet.ahrq.gov/web-mm/magnetic-deflectionNovember 18, 2016 - The Magnetic Deflection Citation Text: Kanal E. The Magnetic Deflection. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49396/psn-pdfApril 01, 2003 - The 2-Week Itch April 1, 2003 Cohen MR. The 2-Week Itch. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/2-week-itch The Case A 40-year-old woman with bipolar disorder (on trazodone) came to her primary care physician with new urticaria. She received a handwritten prescription for Zyrtec and Atarax. The ha… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49580/psn-pdfMarch 21, 2009 - Medication Reconciliation Victory After an Avoidable Error March 21, 2009 Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error The Case A 91-year-old woman, previously active and indepen… -
psnet.ahrq.gov/web-mm/medication-overdoseSeptember 01, 2011 - Medication Overdose Citation Text: Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865698/psn-pdfApril 24, 2024 - Patient Safety Amid Nursing Workforce Challenges April 24, 2024 Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges Introduction Nurses are essential to patient care, and having a… -
psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-maFebruary 26, 2025 - There are TeamSTEPPS training programs, which can be amazing, but take time and energy and you need … from the issue of resilience and readiness of the providers, what else have we learned about teamwork training … programs and other ways of trying to improve more traditionally defined safety culture?
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Spotlight (pdf file)
psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdfJanuary 01, 2022 - Editor: Meghan Weyrich, MPH 2 https://psnet.ahrq.gov/webmm Objectives At the conclusion of this educational … activity, participants should be able to: • Describe the role of intraosseous (IO) vascular access -
psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdfJanuary 01, 2023 - Patricia Poole, PharmD o Managing Editor: Meghan Weyrich, MPH 2 Objectives At the conclusion of this educational … activity, participants should be able to: • Describe the signs and symptoms of gabapentin toxicity
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Spotlight (pdf file)
psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdfJanuary 01, 2024 - Editor: Meghan Weyrich, MPH 2 https://psnet.ahrq.gov/webmm Objectives At the conclusion of this educational … activity, participants should be able to: • Recognize the importance of maintaining sinus rhythm in -
psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreementSeptember 24, 2024 - dashboards to track harms and sought to define themselves as a learning health system by deploying an education … Perspectives on Safety The Role of Undergraduate Nursing Education
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49624/psn-pdfMay 01, 2011 - Talking with Patients and Families about Medical Error: A Guide for Education and Practice.
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