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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72616/psn-pdf
    December 22, 2020 - Adverse Events in Dentistry December 22, 2020 Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/adverse-events-dentistry Introduction Similar to many other healthcare settings, dentistry carries with it inherent patient safety risks. D…
  2. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.365_slideshow.ppt
    January 01, 2016 - PowerPoint Presentation Spotlight A Room Without Orders 1 This presentation is based on the January 2016 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Amy Vogelsmeier, PhD, RN, Sinclair School of Nursing; and Laurel Despins, PhD, RN, Sinclair Sc…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33777/psn-pdf
    January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care January 1, 2015 Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33798/psn-pdf
    January 01, 2015 - Accountability in Patient Safety January 1, 2015 Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/accountability-patient-safety Annual Perspective 2015 The tension between the no-blame culture espoused in the early years of the safety movement and …
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
    February 01, 2018 - PowerPoint Presentation Spotlight Signout Fallout 1 Source and Credits This presentation is based on the February 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…
  6. psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
    April 27, 2022 - Readmissions and Adverse Events After Discharge Citation Text: Readmissions and Adverse Events After Discharge. 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…
  7. psnet.ahrq.gov/primer/diagnostic-errors
    June 15, 2024 - Diagnostic Errors Citation Text: Diagnostic Errors. 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 PubMedId RIS Dow…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33587/psn-pdf
    June 15, 2024 - Missed Nursing Care June 15, 2024 Missed Nursing Care. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/missed-nursing-care 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. Last reviewed…
  9. psnet.ahrq.gov/primer/falls
    October 27, 2021 - Falls Citation Text: Falls. 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 PubMedId RIS Download Citation …
  10. psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - Taxonomy of Communication Failures Type of Communication Failure Examples Failure
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866578/psn-pdf
    August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy August 28, 2024 Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…
  12. psnet.ahrq.gov/web-mm/delirium-or-dementia
    September 27, 2023 - SPOTLIGHT CASE Delirium or Dementia? Citation Text: Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…
  13. psnet.ahrq.gov/web-mm/cognitive-overload-icu
    June 01, 2005 - SPOTLIGHT CASE Cognitive Overload in the ICU Citation Text: Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTe…
  14. psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
    February 01, 2004 - SPOTLIGHT CASE Delay in Treatment: Failure to Contact Patient Leads to Significant Complications Citation Text: Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33833/psn-pdf
    May 01, 2017 - In Conversation With… David Juurlink, MD, PhD May 1, 2017 In Conversation With… David Juurlink, MD, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd Editor's note: Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of Toronto, w…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49553/psn-pdf
    January 01, 2008 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures January 1, 2008 Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures The…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49721/psn-pdf
    December 01, 2014 - Ebola: Are We Ready? December 1, 2014 Barsuk JH, Barnard C. Ebola: Are We Ready? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/ebola-are-we-ready The Case A 28-year-old man, well-appearing but pale, walked into the emergency department (ED) on a Wednesday afternoon at 3 PM complaining of nausea, vomiting,…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49753/psn-pdf
    February 01, 2016 - Robotic Surgery: Risks vs. Rewards February 1, 2016 Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards Case Objectives Discuss the background and current trends in robotic surgery. Identify the benefits of robotic s…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861738/psn-pdf
    January 31, 2024 - A Laceration that Needed a Proper Exam, Not an X-Ray January 31, 2024 Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray Disclosure of Relevant Financial Relationships: As a provider accredited by t…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33873/psn-pdf
    February 01, 2019 - In Conversation With… Susan E. Skochelak, MD, PhD February 1, 2019 In Conversation With… Susan E. Skochelak, MD, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd Editor's note: Dr. Skochelak is the Group Vice President for Medical Education at the American Medica…

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