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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - For this reason, the responsibility
of obtaining such details falls on both the surgical and anesthesia
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psnet.ahrq.gov/node/61078/psn-pdf
October 28, 2020 - Based on the experiences of these
authors, it typically falls on the patient/family and consulting diabetes
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psnet.ahrq.gov/node/33788/psn-pdf
June 01, 2015 - Or a patient falls or gets what might be a preventable pressure ulcer, or a mistake occurs in a
surgical
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - Levels of Sedation The ASA has identified four levels of sedation (Table 2). 8 Typical sedation for MRI falls
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psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
January 03, 2017 - Related Resources
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - May 31, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - Perspective
The Ongoing Journey to Prevent Patient Falls
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - May 31, 2023
Patient Safety Innovations
Preventing Falls
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - When, as in this case, data falls outside what the mental model predicts or therapy does not produce
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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.
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psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
July 01, 2011 - September 22, 2021
WebM&M Cases
Falling Between the Cracks
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
October 01, 2007 - be lethargic, opening her eyes and mumbling incoherently in response to vigorous shaking but quickly falling
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - June 24, 2020
Information flow during pediatric trauma care transitions: things falling
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psnet.ahrq.gov/node/49429/psn-pdf
January 01, 2004 - Ruptured Heterotopic Pregnancy
January 1, 2004
Cedars MI. Ruptured Heterotopic Pregnancy. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
The Case
A 43-year-old woman, gravida 3 para 2, presented at 16 weeks' gestational age with abdominal pain. Her
current pregnancy was the r…
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psnet.ahrq.gov/node/49539/psn-pdf
June 01, 2007 - Informed or Misled?
June 1, 2007
White SM. Informed or Misled? . PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/informed-or-misled
The Case
A 50-year-old man arrived at the hospital for an elective total knee replacement. Based on preoperative
discussions, the patient expected to receive spinal anesthesia.…
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - emergency department (ED) from a nursing facility due to decreased
oral intake, fevers, confusion, and falling
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psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - patients, which could reduce the risk of heart attack and stroke that may lead to potential disability and falls … augment that with telehealth where you get a view into someone's home and see if there are tripping or falling
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psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - patients, which could reduce the risk of heart attack and stroke that may lead to potential disability and falls … augment that with telehealth where you get a view into someone's home and see if there are tripping or falling
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/node/846564/psn-pdf
March 29, 2023 - Technology as a Tool for Improving Patient Safety
March 29, 2023
Holmgren AJ, McBride S, Gale B, et al. Technology as a Tool for Improving Patient Safety . PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
Introduction
In the past several decades, technological a…