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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - stenosis)
• Patient was admitted for a pathologic pelvic fracture
(secondary to osteoporosis) after a fall
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psnet.ahrq.gov/node/49823/psn-pdf
March 01, 2018 - dL) postingestion than at 4 hours (150 mg/dL).(11) This is because the measured
concentration will fall
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psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
February 17, 2021 - Diagnostic Pitfalls Diagnostic pitfalls are common “traps” that clinicians and teams fall into during
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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - drugs used by anesthesia practitioners are administered by IV push or IV
infusion, and many of them fall
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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - The error occurs when individuals fall victim to the flaws within the system and mistakes are made.
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - team members to the task at hand and enable them to "speak up" or challenge something that seems to fall
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psnet.ahrq.gov/web-mm/think-surgeon
December 04, 2024 - October 19, 2022
ROI for a fall prevention intervention: invest a little, save a lot.
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psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
November 16, 2022 - Report of Findings from the Practice and Professional Survey, Fall 2004.
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psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
December 21, 2018 - at discharge.( 3 ) When the costs exceed this payment the hospital incurs a loss, and when the costs fall
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psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
March 01, 2004 - April 1, 2013
Perspective
Implementing a Fall Prevention
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psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
July 19, 2023 - potentially fatal conditions like pancreatitis, but with respect to communication and coordination, we often fall
-
psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
January 29, 2020 - Deadly Duo
October 1, 2010
Evaluation of clinical practice guidelines on fall
-
psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - presented to a Level III trauma center with bilateral lower extremity paralysis following a
ground level fall
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psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - Lane-Fall MB, Beidas RS, Pascual JL, et al.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.101_slideshow.ppt
July 01, 2005 - dose, it takes about 20 hours before any significant change in INR because factor VII levels have to fall
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Deadly Duo
October 1, 2010
Evaluation of clinical practice guidelines on fall
-
psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
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psnet.ahrq.gov/node/866217/psn-pdf
July 10, 2024 - In Conversation With...Amy Helwig about Health Plan
Patient Safety Initiatives
July 10, 2024
Helwig A, Sousane Z, Mossburg S. In Conversation With..Amy Helwig about Health Plan Patient Safety
Initiatives. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patie…
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psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - Application of Safety-II Principles
August 28, 2024
Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/application-safety-ii-principles
Traditional approaches to patient safety have often been reactive rather than proactive, seeki…
-
psnet.ahrq.gov/node/73146/psn-pdf
April 28, 2021 - Patient Safety in Home Dialysis
April 28, 2021
Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/patient-safety-home-dialysis
Dialysis Care and Patient Safety Concerns
In patients with chronic kidney disease, kidney function declines ov…