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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - Ensure everyone has a safety awareness focus.
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psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
November 15, 2023 - Innovation Patient Safety Focus
The Hospital at Home program provides inpatient-level care to patients
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - Future quality improvement efforts aimed at reducing psychiatric misdiagnosis should focus on standardizing
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Acute Pulmonary Embolism: Focus on the Clinical Picture.
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psnet.ahrq.gov/node/843234/psn-pdf
January 01, 2013 - Entries may not
contain information on disease severity (such as GFR level) necessary to focus alerts
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - encouraged to be vigilant about wearing a mask, to stay in one room of the house if possible, and to focus
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - This suggests that the clinicians initially considered trauma but prematurely narrowed their focus to
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psnet.ahrq.gov/innovation/stoplight-mobility-alert-system-safety-and-prevention-falls-children-physical-and
September 14, 2022 - EMERGING INNOVATIONS
The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments.
Citation Text:
The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments. Mullen JB,&nbs…
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psnet.ahrq.gov/periodic-issue/periodic-issue-294
June 30, 2021 - June 2, 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, a…
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psnet.ahrq.gov/periodic-issue/periodic-issue-331
March 31, 2022 - March 2, 2022 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/861760/psn-pdf
January 31, 2024 - Syringe Swap During Regional Block: A Case of
Medication Error and Recovery
January 31, 2024
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - Unseen Perils of Urinary Catheters
June 1, 2015
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
The Case
A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
June 28, 2023
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue
Necrosis and Cuff Rupture. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…
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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/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/perspective/conversation-john-d-birkmeyer-md
January 31, 2024 - In Conversation With… John D. Birkmeyer, MD
May 1, 2015
Citation Text:
In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Fo…
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - Delayed Diagnosis of Mesenteric Ischemia
August 31, 2022
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
November 13, 2024 - Delayed Diagnosis of Endocrinologic Emergencies
Citation Text:
Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google …
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psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
December 02, 2020 - Updates in the Management of High-Risk Pulmonary Embolism
Citation Text:
Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Forma…
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psnet.ahrq.gov/node/865413/psn-pdf
March 27, 2024 - In Conversation with...Barbara Pelletreau and John Riggi
about Cybersecurity
March 27, 2024
Pelletreau B, Riggi J. In Conversation with..Barbara Pelletreau and John Riggi about Cybersecurity. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cyberse…