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3581. Toxic Tachycardia | PSNet
      psnet.ahrq.gov/web-mm/toxic-tachycardia
      March 01, 2005 - Toxic Tachycardia Citation Text: Wartofsky L. Toxic Tachycardia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

3582. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49844/psn-pdf
      October 01, 2018 - Diffusion of Responsibility Leads to Danger October 1, 2018 Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger The Case A 70-year-old man was sent to the emergency department (ED) from a nursing facility…

3583. The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm | PSNet
      psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
      February 26, 2025 - The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January 5, 2021 Innovation Contact …

3584. Misidentifying the Unidentified – John Doe and the EHR | PSNet
      psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
      September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR Citation Text: Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …

3585. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867652/psn-pdf
      February 26, 2025 - The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis Introduction Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…

3586. A Picture Speaks 1000 Words | PSNet
      psnet.ahrq.gov/web-mm/picture-speaks-1000-words
      July 16, 2015 - A Picture Speaks 1000 Words Citation Text: Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

3587. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33856/psn-pdf
      April 01, 2018 - Patient Safety During Hospital Discharge April 1, 2018 Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge Perspective Patients are admitted to the hospital in the United States 35 million times per year.(1)…

3588. Getting the (Right) Doctor, Right Away | PSNet
      psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
      July 01, 2011 - Getting the (Right) Doctor, Right Away Citation Text: Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X…

3589. Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
      January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx Spotlight When the Indications for Drug Administration Blur Source and Credits • This presentation is based on the June 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Julia Munsch,…

3590. Mixup Beyond the Medication Label | PSNet
      psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
      June 01, 2014 - Mixup Beyond the Medication Label Citation Text: Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote …

3591. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865698/psn-pdf
      April 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…

3592. Medication/Drug Errors | PSNet
      psnet.ahrq.gov/curated-library/medicationdrug-errors
      March 12, 2021 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Medication/Drug Errors  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Dr. Yan Xiao, AHRQ TEP Member Date…

3593. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33600/psn-pdf
      June 16, 2024 - Patient Safety 101 June 16, 2024 Patient Safety 101. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/patient-safety-101 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 in…

3594. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33581/psn-pdf
      December 15, 2024 - Medication Errors and Adverse Drug Events December 15, 2024 Medication Errors and Adverse Drug Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect cu…

3595. Strategies to Improve Organizational Health Literacy. | PSNet
      psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
      August 30, 2023 - Strategies to Improve Organizational Health Literacy. Citation Text: Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format:…

3596. Improving Patient Safety and Team Communication through Daily Huddles | PSNet
      psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
      December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles Citation Text: Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citatio…

3597. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis | PSNet
      psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
      March 09, 2022 - minimize CSF leak, mimic the compliance of dura, and be biologically inert. 48 Currently, the options fall … Commercially available sealants fall into two categories as either synthetic, consisting of polyethylene

3598. Transfusion Thresholds in Gastrointestinal Bleeding | PSNet
      psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
      November 26, 2014 - In such cases, the hemoglobin tends to fall precipitously and waiting can result in delayed and insufficient

3599. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49501/psn-pdf
      February 03, 2006 - Catastrophe requires multiple failures—a single point failure is not enough.”(14) Communication failures fall

3600. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49828/psn-pdf
      May 01, 2018 - provider is unavailable or distracted, creating opportunities for critical pieces of information to fall