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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60269/psn-pdf
    April 29, 2020 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? April 29, 2020 Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tiss…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49608/psn-pdf
    August 01, 2010 - Emergent Triage Miss August 1, 2010 Travers D. Emergent Triage Miss. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/emergent-triage-miss The Case A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage nurse. The patient told the triage nurse that she had "3 days o…

  3. Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx Spotlight Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842923/psn-pdf
    February 01, 2023 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. February 1, 2023 Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. PSNet [internet]. …

  5. Failure to Latch | PSNet

    psnet.ahrq.gov/web-mm/failure-latch
    November 27, 2012 - Failure to Latch Citation Text: Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42422/psn-pdf
    November 18, 2013 - Resilient actions in the diagnostic process and system performance. November 18, 2013 Smith MW, Giardina TD, Murphy DR, et al. Resilient actions in the diagnostic process and system performance. BMJ Qual Saf. 2013;22(12):1006-13. doi:10.1136/bmjqs-2012-001661. https://psnet.ahrq.gov/issue/resilient-actions-diagnos…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60193/psn-pdf
    July 01, 2022 - Improving Diagnosis and Treatment of Maternal Sepsis. April 1, 2020 Stanford, CA; California Maternal Quality Care Collaborative: July 1, 2022.  https://psnet.ahrq.gov/issue/improving-diagnosis-and-treatment-maternal-sepsis This toolkit focuses on identification of, and rapid response to, sepsis in obstetric p…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33895/psn-pdf
    April 01, 2024 - The Leapfrog Hospital Survey. April 1, 2024 Leapfrog Group. https://psnet.ahrq.gov/issue/leapfrog-hospital-survey This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time a…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44679/psn-pdf
    November 18, 2015 - Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps. November 18, 2015 ISMP Medication Safety Alert! Acute Care Edition. November 5, 2015;20:1-5. https://psnet.ahrq.gov/issue/key-vulnerabilities-surgical-environment-container-mix-ups-and-syringe-swaps The perioperative environment …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38936/psn-pdf
    September 09, 2009 - Therapeutic errors involving adults in the community setting: nature, causes and outcomes. September 9, 2009 Taylor D, Robinson J, MacLeod D, et al. Therapeutic errors involving adults in the community setting: nature, causes and outcomes. Aust N Z J Public Health. 2009;33(4):388-94. doi:10.1111/j.1753- 6405.2009.…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866528/psn-pdf
    August 14, 2024 - First with Kids: Medication Errors. August 14, 2024 First L. NBC5. First with Kids: Medication Errors. August 1, 2024. https://psnet.ahrq.gov/issue/first-kids-medication-errors Medication mistakes involving children are common. This news segment provides suggestions for parents to help improve the safety of medica…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42858/psn-pdf
    January 15, 2014 - Early access to a neurologist reduces the rate of missed diagnosis in young strokes. January 15, 2014 Mohamed W, Bhattacharya P, Chaturvedi S. Early access to a neurologist reduces the rate of missed diagnosis in young strokes. J Stroke Cerebrovasc Dis. 2013;22(8):e332-7. doi:10.1016/j.jstrokecerebrovasdis.2013.01…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43682/psn-pdf
    November 19, 2014 - Pearls, Pitfalls, and Errors in Musculoskeletal Diagnosis. November 19, 2014 Blankenbaker DG, ed. AJR Am J Roentgenol. 2014;203(3):476-593. https://psnet.ahrq.gov/issue/pearls-pitfalls-and-errors-musculoskeletal-diagnosis Articles in this special issue discuss common pitfalls in musculoskeletal imaging that can con…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39027/psn-pdf
    September 29, 2017 - Disclosing clinical adverse events to patients: can practice inform policy? September 29, 2017 Sorensen R, Iedema R, Piper D, et al. Disclosing clinical adverse events to patients: can practice inform policy? Health Expect. 2010;13(2):148-59. doi:10.1111/j.1369-7625.2009.00569.x. https://psnet.ahrq.gov/issue/discl…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840494/psn-pdf
    November 30, 2022 - Safety of anesthetic and perioperative medication practices. November 30, 2022 Meyer TA. Anesthesiology News. October 31, 2022. https://psnet.ahrq.gov/issue/safety-anesthetic-and-perioperative-medication-practices Medication use in the surgical environment is complex and high-risk. This article describes steps tow…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853627/psn-pdf
    September 20, 2023 - Understanding And Addressing Pre-Hospital Diagnostic Delays. September 20, 2023 Health Affairs Forefront; May-September 2023. https://psnet.ahrq.gov/issue/understanding-and-addressing-pre-hospital-diagnostic-delays Diagnostic delays stem from both human and process failures. This series of articles examines how s…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73872/psn-pdf
    September 22, 2021 - Parenteral nutrition safety. September 22, 2021 Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20. https://psnet.ahrq.gov/issue/parenteral-nutrition-safety Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43411/psn-pdf
    October 01, 2014 - Analysis of medication errors in simulated pediatric resuscitation by residents. October 1, 2014 Porter E, Barcega B, Kim TY. Analysis of medication errors in simulated pediatric resuscitation by residents. West J Emerg Med. 2014;15(4):486-90. doi:10.5811/westjem.2014.2.17922. https://psnet.ahrq.gov/issue/analysis…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37155/psn-pdf
    October 06, 2011 - Classification of adverse events occurring in a surgical intensive care unit. October 6, 2011 Frankel H, Sperry J, Kaplan L, et al. Classification of adverse events occurring in a surgical intensive care unit. Am J Surg. 2007;194(3):328-32. https://psnet.ahrq.gov/issue/classification-adverse-events-occurring-surgi…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36759/psn-pdf
    August 10, 2011 - Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. August 10, 2011 Bressler B, Paszat LF, Chen Z, et al. Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. Gastroenterology. 2007;132(1):96-10…
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