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  1. 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
  2. psnet.ahrq.gov/web-mm/failure-rescue-mother
    September 23, 2020 - January 15, 2017 Evaluation of clinical practice guidelines on fall prevention and management
  3. psnet.ahrq.gov/web-mm/check-twice-transport-once
    March 15, 2023 - Hole October 1, 2003 WebM&M Cases Another Fall
  4. 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
  5. psnet.ahrq.gov/web-mm/complaints-safety-surveillance
    May 05, 2021 - Issues contributing to complaints fall into three broad categories: conduct (personal behavior below
  6. psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
    November 15, 2023 - December 9, 2020 A randomized trial of a multifactorial strategy to prevent serious fall
  7. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - male with a history of chronic opioid use, anxiety disorder, and major depression presented after a fall
  8. psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
    October 01, 2008 - In Conversation with…Robert M. Wachter, MD October 1, 2008  Also Read an Essay Citation Text: In Conversation with…Robert M. Wachter, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008…
  9. psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
    April 28, 2021 - In Conversation With... José A, Morfín, MD, FASN April 28, 2021  Also Read the Essay Citation Text: In Conversation With.. José A, Morfín, MD, FASN. PSNet [internet]. 2021.In Conversation With... José A, Morfín, MD, FASN. PSNet [internet]. Rockville (MD): Agency f…
  10. psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
    July 01, 2011 - In Conversation with…William B. Munier, MD, MBA July 1, 2011  Also Read an Essay Citation Text: In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
  11. psnet.ahrq.gov/perspective/care-transitions
    December 01, 2007 - know health care delivery backwards and forwards—are themselves not immune from seeing these issues fall
  12. psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
    November 03, 2015 - Health Care Worker Presenteeism: A Challenge for Patient Safety Julia E. Szymczak, PhD | October 1, 2017  View more articles from the same authors. Citation Text: Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. Rockvi…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49632/psn-pdf
    July 01, 2011 - A Seasonal Care Transition Failure July 1, 2011 Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure The Case A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine resident—for routine follow-up…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33751/psn-pdf
    January 01, 2014 - Strengthening the Business Case for Patient Safety May 1, 2013 Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety Perspective After more than a decade in the national spotlight, the problem of pati…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49707/psn-pdf
    April 01, 2014 - CYP450 Drugs: Expect the Unexpected April 1, 2014 Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected The Case A 42-year-old man with acquired immunodeficiency syndrome (AIDS) (CD4 count 198), hip dystocia, and generalized anxiety …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49711/psn-pdf
    June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of Patient Wandering June 1, 2014 Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering Case Objectives Define patie…
  17. psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
    October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019  View more articles from the same authors. Citation Text: Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49407/psn-pdf
    July 01, 2003 - Bleeding Risk July 1, 2003 Crowther MA. Bleeding Risk. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/bleeding-risk The Case A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial fibrillation, hypertension, coronary artery disease, and stroke. The surgi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33685/psn-pdf
    May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA May 1, 2009 In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and Family M…
  20. psnet.ahrq.gov/primer/patient-safety-101
    January 16, 2025 - Patient Safety 101 Citation Text: Patient Safety 101. 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 D…

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