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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - In Conversation With… Matthew Weinger, MD
August 1, 2018
In Conversation With… Matthew Weinger, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
Editor's note: Dr. Weinger is Director of the Center for Research and Innovation in Systems Safety and
Professor of Anesthes…
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Total Parenteral Nutrition, Multifarious Errors
April 1, 2013
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
Case Objectives
Define parenteral nutrition (PN).
Describe the PN-use process.
Identify …
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - SPOTLIGHT CASE
Patient Safety Events Involving Opioid Dose Stacking
Citation Text:
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Copy Cita…
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psnet.ahrq.gov/node/33726/psn-pdf
March 01, 2012 - I think we
need to focus on making it less of a game.
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - patient engagement, patient adherence promotion, and in administrative activities. 3 However, the focus
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - There's enough evidence from that kind of system that when it is implemented people can focus on, first
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - Entries may not contain information on disease severity (such as GFR level) necessary to focus alerts
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - There's enough evidence from that kind of system that when it is implemented people can focus on, first
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psnet.ahrq.gov/node/36455/psn-pdf
December 22, 2010 - Changing the work environment in ICUs to achieve
patient-focused care: the time has come.
December 22, 2010
McCauley K, Irwin RS. Changing the work environment in ICUs to achieve patient-focused care: the time
has come. Chest. 2006;130(5):1571-8.
https://psnet.ahrq.gov/issue/changing-work-environment-icus-achieve-…
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psnet.ahrq.gov/node/60744/psn-pdf
July 29, 2020 - guidelines for ACS/MI and their gender-specific
subsections.14, 28-31 However, it is not sufficient to focus
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Neurosurg Focus 2019;46(1):E4.
11.
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psnet.ahrq.gov/node/34021/psn-pdf
March 07, 2005 - Focusing on Medical Errors.
March 7, 2005
Temple WJ, ed. J Surg Oncol. 2004;88(3):111-199.
https://psnet.ahrq.gov/issue/focusing-medical-errors
This issue provides a review of medical error from a variety of perspectives, including pediatrics,
anesthesiology, pharmacy, pathology, laboratory medicine, and insurers.…
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psnet.ahrq.gov/node/34022/psn-pdf
March 07, 2005 - Focusing on Health Care Safety.
March 7, 2005
IEEE Transactions on Systems, Man, and Cybernetics, Part A: Systems and Humans. 2004;34(601):689-
778.
https://psnet.ahrq.gov/issue/focusing-health-care-safety
This special issue covers concepts of cognition, the use of planning and protocols, communication
patterns, …
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psnet.ahrq.gov/node/39703/psn-pdf
March 18, 2016 - Patient Safety Culture Report: Focusing on Indicators.
March 18, 2016
Utrecht, Netherlands: European Network for Patient Safety; 2010.
https://psnet.ahrq.gov/issue/patient-safety-culture-report-focusing-indicators
This report identifies care process and outcome indicators in the European Union and describes how the…
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psnet.ahrq.gov/node/38169/psn-pdf
June 11, 2018 - Collaboration focused on priority issues promotes safety.
June 11, 2018
ISMP Medication Safety Alert! Acute Care Edition. October 10, 2008;13:1-3.
https://psnet.ahrq.gov/issue/collaboration-focused-priority-issues-promotes-safety
Reporting that recalled medications were found in hospital pharmacies, this article
d…
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room.
Citation Text:
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/node/867022/psn-pdf
October 30, 2024 - Delayed Symptomatic Subdural Hematoma Following an
Initially Normal CT Head
October 30, 2024
Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-h…
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - SPOTLIGHT CASE
Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture
Citation Text:
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…