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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - March 8, 2023
6-PACK programme to decrease fall injuries in acute hospitals: cluster
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - CYP450 Drugs: Expect the Unexpected
Citation Text:
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/49594/psn-pdf
December 01, 2009 - Standard Deviations
December 1, 2009
Sabin JE. Standard Deviations. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/standard-deviations
Case Objectives
Understand the safety risks associated with patients being discharged against medical advice
(AMA).
Recognize safety risks associated with being part of a …
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - SPOTLIGHT CASE
Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery
Citation Text:
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - November 27, 2023
Perspectives on Safety
Suicide Prevention … Interview
In Conversation with Edwin Boudreaux about Suicide Prevention
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psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - That's the hard part with prevention is it never gets the glory because it stopped happening and we don't … of surveillance systems could move the EMS profession to a higher level of patient safety focused on prevention … consistently linked to safety outcomes, and serves as a foundation for the provision of safe patient care and prevention … Interview
In Conversation with Edwin Boudreaux about Suicide Prevention … Journal Article
Study
Catching those who fall
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - and a thoracic aortic aneurysm presented to the Emergency Department (ED) after a syncopal event and fall
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - and a thoracic aortic aneurysm presented to the Emergency Department (ED) after a syncopal event and
fall
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psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
March 01, 2009 - Francisco, Director of the UCSF Center for Vulnerable Populations, and Chief of the California Diabetes Prevention … thinking about the period of time between visits as an opportunity to be proactive before patients fall … Medication errors in chemotherapy: incidence, types and involvement of patients in prevention
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psnet.ahrq.gov/node/837784/psn-pdf
August 05, 2022 - I am core faculty of the Johns
Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease … devices or have internet access but for people who don’t have those things; it is for people who might
fall … plenty of use cases for smartphone applications in the cardiology space demonstrating that
secondary prevention
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psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
December 01, 2014 - The first one was on infection prevention and control and really working on hand hygiene. … Similarly in infection prevention we have one of the world's experts working on the team. … Then some of these tools, either through Internet or mobile phone programs, can fall on fertile ground
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
February 26, 2025 - In Conversation With… Kaveh Shojania, MD
November 1, 2015
Citation Text:
In Conversation With… Kaveh Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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For…
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psnet.ahrq.gov/classics
August 01, 2023 - Classics and Emerging Classics
To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient sa…
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - tube (ETT) placement was confirmed by auscultation of breath sounds and observation of chest rise and fall
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psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
July 01, 2003 - The Case An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility
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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…
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - Air
October 1, 2004
WebM&M Cases
Another Fall
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions,
and Complications and Enhances Satisfaction for Elderly
Patients.
April 7, 2021
https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-
and-enhances
Summary
The Hospital at Homesm program provides hospital-level care…
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psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
March 22, 2009 - Francisco, Director of the UCSF Center for Vulnerable Populations, and Chief of the California Diabetes Prevention … thinking about the period of time between visits as an opportunity to be proactive before patients fall … Medication errors in chemotherapy: incidence, types and involvement of patients in prevention