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psnet.ahrq.gov/periodic-issue/periodic-issue-312
October 27, 2021 - October 6, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports…
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psnet.ahrq.gov/periodic-issue/periodic-issue-430
March 27, 2024 - March 6, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/node/49486/psn-pdf
August 21, 2005 - 20 hours before there is any
significant change in the INR (because factor VII levels first have to fall
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Do Not Disturb!
October 1, 2007
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/do-not-disturb
Case Objectives
Define professionalism.
Discuss behaviors associated with lack of professionalism.
Outline steps one should take if a significant breach of professionalism is …
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - January 1, 2004
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.
Citation Text:
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNot…
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight
in Cardiac Surgery
April 24, 2024
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - Spotlight
Spotlight
Missed Connection: A Case of Inadequate ECG
Oversight in Cardiac Surgery
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Christian Bohringer, MBBS, …
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - Human errors and their prevention in healthcare. … Human errors and their prevention in healthcare.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - PowerPoint Presentation
Spotlight
A Pill Organizing Plight
*
Source and Credits
This presentation is based on the September 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Ro…
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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/node/33793/psn-pdf
November 01, 2015 - In Conversation With… Kaveh Shojania, MD
November 1, 2015
In Conversation With… Kaveh Shojania, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
Editor's note: Kaveh Shojania, MD, is Editor-in-Chief of BMJ Quality and Safety and Director of the
Centre for Quality Impro…
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psnet.ahrq.gov/issue/indiana-medical-error-reporting-system-final-report-2015
July 15, 2009 - Multi-use Website
Indiana Medical Error Reporting System.
Citation Text:
Indiana Medical Error Reporting System. Indianapolis, IN: Indiana State Department of Health.
Copy Citation
Save
Save to your library
Print
Download PDF
Share
Facebook
…
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - while being cared for in a health care facility
Patient death or serious disability associated with a fall … February 25, 2015
Exploring the causes of adverse events in hospitals and potential prevention
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psnet.ahrq.gov/periodic-issue/periodic-issue-318
November 30, 2021 - This funding announcement calls for program applications to motivate suicide prevention strategy implementation … The patient subsequently presented to Emergency Department after a fall at home and was found to have
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psnet.ahrq.gov/periodic-issue/periodic-issue-317
November 30, 2021 - Review
Prevention of failure to rescue in obstetric patients: a realist review. … The patient subsequently presented to Emergency Department after a fall at home and was found to have
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psnet.ahrq.gov/node/49623/psn-pdf
March 01, 2011 - Report of Findings from the Practice and Professional
Survey, Fall 2004.
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psnet.ahrq.gov/node/49443/psn-pdf
May 01, 2004 - Privacy Gone Awry
May 1, 2004
Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/privacy-gone-awry
The Case
A 3-year-old child underwent bilateral myringotomies and tube insertion with adenoidectomy.
Preoperatively, she had an upper respiratory infection, but was eating…
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psnet.ahrq.gov/curated-article-libraries
March 18, 2025 - Curated Libraries
Curated Libraries are groupings of PSNet content, curated by AHRQ and by other experts in the patient safety field.
Watch the video to learn more about how this new feature works and how it can be of benefit to you.
Latest PSNet…