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  1. 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…
  2. 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, …
  3. Psn-Pdf (pdf file)

    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
  4. Psn-Pdf (pdf file)

    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 …
  5. 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
  6. 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…
  7. 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…
  8. Psn-Pdf (pdf file)

    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…
  9. Spotlight (pdf file)

    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, …
  10. 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.
  11. 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…
  12. 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
  13. Psn-Pdf (pdf file)

    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…
  14. 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 …
  15. 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
  16. 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
  17. 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
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49623/psn-pdf
    March 01, 2011 - Report of Findings from the Practice and Professional Survey, Fall 2004.
  19. Psn-Pdf (pdf file)

    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…
  20. 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…

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