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psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - an unsteady gait, suggesting pelvic muscle weakness and requiring use of a “tether” to keep her from falling
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psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - Pressure Ulcer Prevention in the Hospital Setting Using
Silicone Foam Dressings.
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - Difficult Encounters: A CMO and CNO Respond
October 1, 2009
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
Case Objectives
Appreciate the risk of disruptive behavior and understand institutional respons…
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - infection (such as catheter-associated urinary tract infection or aspiration pneumonia), pressure ulcers, falls
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - negative CT interpretation would result in a treatment plan that does not include measures aimed at prevention
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psnet.ahrq.gov/node/865884/psn-pdf
May 29, 2024 - unsteady gait, suggesting pelvic muscle weakness and
requiring use of a “tether” to keep her from falling
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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - First, diagnostic errors are often confused with errors of screening, prevention, and management and
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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
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - February 1, 2012
Perspective
Implementing a Fall Prevention
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - In Conversation With… Mark L. Graber, MD
January 1, 2016
In Conversation With… Mark L. Graber, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
Editor's note: Dr. Graber is a Senior Fellow at RTI International and Professor Emeritus of Medicine at
the State University o…
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - specific things, like the safety harm scenarios that nurses commonly experience related to things like falls … patient care learning activities in four spheres of care across the lifespan: wellness and disease prevention … March 27, 2024
Perspectives on Safety
Suicide Prevention … Interview
In Conversation with Edwin Boudreaux about Suicide Prevention
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - common types of events, such as health care–associated infections, medication errors, pressure ulcers, falls … Common events (e.g., health care–associated infections, falls) may be so common that individual hospitals
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psnet.ahrq.gov/node/73553/psn-pdf
July 28, 2021 - I serve as a subject matter expert with CDC [the
Centers for Disease Control and Prevention] in emergency … would know when they need to report a quality issue
shortly after it occurred, or when something is falling
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psnet.ahrq.gov/periodic-issue/periodic-issue-424
January 04, 2024 - delay in essential nursing care) adversely impacts patient safety, contributing to higher incidence of falls
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 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/production-pressures
November 16, 2022 - January 20, 2021
Information flow during pediatric trauma care transitions: things falling
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psnet.ahrq.gov/node/861881/psn-pdf
January 31, 2024 - In Conversation with...Richard Ricciardi about Office-
Based Patient Safety
January 31, 2024
Ricciardi R, Lee M, Mossburg S. In Conversation with..Richard Ricciardi about Office-Based Patient Safety.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-pa…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - reported included
Medication errors (17.2/100 discharges)
Adverse drug events (4.1/100 discharge)
Falls
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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Lost in Transition
February 1, 2006
Beach C. Lost in Transition. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/lost-transition
Case Objectives
Provide an overview of transitions in continuously operating industries
Review cognitive error
Describe the complex dynamics of transitions in emergency care
Pro…