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3521. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33824/psn-pdf
      January 01, 2016 - Patient Safety and Opioid Medications January 1, 2016 Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications Annual Perspective 2016 Opioid medications confer significant risks of harm, including overdose death …

3522. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49839/psn-pdf
      August 01, 2018 - Mixup Beyond the Medication Label August 1, 2018 Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label The Case An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another hospi…

3523. Measuring and Responding to Deaths From Medical Errors | PSNet
      psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
      April 01, 2008 - Annual Perspective Measuring and Responding to Deaths From Medical Errors Sumant Ranji, MD | March 22, 2016  View more articles from the same authors. Citation Text: Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. Rockville…

3524. Topics | PSNet
      psnet.ahrq.gov/topics-0
      March 03, 2025 - Topics Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Featured Topics in Patient Safety Updated Date: March 3, 2025 …

3525. Patient Engagement in Safety | PSNet
      psnet.ahrq.gov/perspective/patient-engagement-safety
      January 01, 2018 - Annual Perspective Patient Engagement in Safety Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2017  View more articles from the same authors. Citation Text: Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. Rockville (MD): Agency…

3526. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation | PSNet
      psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
      June 28, 2023 - SPOTLIGHT CASE Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation Citation Text: Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. Rockville (MD): Agency for Healt…

3527. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865454/psn-pdf
      March 27, 2024 - Ensuring Patient and Workforce Safety Culture in Healthcare March 27, 2024 Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare Introduction In 2020, the I…

3528. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions | PSNet
      psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
      November 01, 2008 - RW : There may be some trade-offs in terms of patients being forced out of bed and an increased fall

3529. Hospital at Home℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. | PSNet
      psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
      November 15, 2023 - Hospital at Home℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL April 7, 2021 Innovation…

3530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852700/psn-pdf
      August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety August 30, 2023 McGaffigan P, Van CM, Mossburg S. In Conversation with.. Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/con…

3531. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846171/psn-pdf
      July 26, 2022 - Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation March 15, 2023 Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/agitated-delirium-contributes…

3532. In Conversation With… Jack Needleman, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
      September 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012  Also Read an Essay Citation Text: In Conversation With… Jack Needleman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012…

3533. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50859/psn-pdf
      January 31, 2020 - Where did it fall through the cracks? That image finding wasn’t on the problem list.

3534. In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO | PSNet
      psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
      January 12, 2022 - They had been a common strategy for fall prevention, but with the requirement to put on PPE, there was … a delay before a staff person could respond to the alarm and prevent a fall.

3535. In Conversation With… Jane Brice, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
      May 01, 2019 - I have seen in the field and as an EMS physician (but also on the receiving end of the EMS patient) fall … And that's one thing that makes it really hard, because 1% of the patients they're going to see will fall

3536. Safety in the Prehospital Emergency Medical Services Setting | PSNet
      psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
      May 01, 2019 - I have seen in the field and as an EMS physician (but also on the receiving end of the EMS patient) fall … And that's one thing that makes it really hard, because 1% of the patients they're going to see will fall

3537. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
      January 12, 2022 - They had been a common strategy for fall prevention, but with the requirement to put on PPE, there was … a delay before a staff person could respond to the alarm and prevent a fall.

3538. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
      January 01, 2024 - minimize CSF leak, mimic the compliance of dura, and be biologically inert.48 Currently, the options fall … suture repair. 26 26 Intraoperative Management – Sealants (2) Commercially available sealants fall

3539. Team Training: Classroom Training vs. High-Fidelity Simulation | PSNet
      psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
      January 12, 2011 - Fall 2002;Q4:20-24. 7. Gaba DM. The future vision of simulation in health care.

3540. Hiding in Plain Sight | PSNet
      psnet.ahrq.gov/web-mm/hiding-plain-sight
      April 24, 2019 - April 24, 2019 An inpatient fall prevention initiative in a tertiary care hospital.