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psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
June 28, 2023 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling
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January 31, 2024
Innovation
Contact
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psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
March 29, 2023 - Walking Out of a Hospital After Attempted Suicide
Citation Text:
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
Googl…
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psnet.ahrq.gov/node/861838/psn-pdf
January 31, 2024 - Adverse Drug Event (ADE) Surveillance and Pharmacist
Counseling
January 31, 2024
https://psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
Summary
Adverse events resulting from medications are a common occurrence that often go undetected, unreported,
and unaddressed.1 The imp…
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - SPOTLIGHT CASE
Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery
Citation Text:
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - Harm From Alarm Fatigue
December 1, 2015
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue
Case Objectives
Define alarm fatigue and describe potential errors that can occur due to alarm fatigue.
Identify federal and national agencies focusing on …
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - Moving Pains
July 1, 2006
Schell H, Wachter R. Moving Pains. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/moving-pains
Case Objectives
Appreciate the risk posed by intrahospital transport
Identify key features of current transport practice and policies
Propose interventions that might improve safety of …
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psnet.ahrq.gov/web-mm/miscalculated-risk
March 01, 2015 - Miscalculated Risk
Citation Text:
Strassels SA. Miscalculated Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
October 01, 2009 - Spotlight Case
Spotlight Case
Difficult Encounters:
A CMO and CNO Respond
Source and Credits
This presentation is based on the October 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Ernie Ring, MD; Jane Hirsch, RN, MS
UCSF Medical Cen…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case April 2006
Is the “Surgical Personality” a Threat to Patient Safety?
Source and Credits
This presentation is based on the April 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary …
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psnet.ahrq.gov/node/33795/psn-pdf
November 01, 2015 - Introducing the Redesigned AHRQ Patient Safety Network
November 1, 2015
Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
Editorial
It's hard to believe that it has been 15 years since th…
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psnet.ahrq.gov/node/49549/psn-pdf
December 06, 2007 - Elopement
December 1, 2007
Gerardi D. Elopement. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/elopement
Case Objectives
Define elopement and differentiate it from wandering and leaving against medical advice.
Identify leading contributors to elopement events.
Describe strategies for preventing elopement…
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - Multifactorial Medication Mishap
February 1, 2014
Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
Case Objectives
Understand the system-based causes of medication errors.
Describe a model for a systems approach to error analysis.
Id…
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - SPOTLIGHT CASE
Moving Pains
Citation Text:
Schell H, Wachter R. Moving Pains. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - Patient and Family Roles in Safety
June 14, 2023
Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety
Moving From Engagement to Partnership
Involving patients and families in healthcare decisions about patient c…
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psnet.ahrq.gov/web-mm/mitigating-risk-intrahospital-transport-pediatric-patients-risk-physiologic-instability
May 27, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability
Citation Text:
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. Rockville (MD): Agency for Heal…
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - SPOTLIGHT CASE
Harm From Alarm Fatigue
Citation Text:
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things
Changed?
June 1, 2014
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
Perspective
In 1981, a cancer patient named Paula Carroll founded…
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psnet.ahrq.gov/node/60174/psn-pdf
March 30, 2020 - Making Healthcare Safer III Report
March 30, 2020
Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
What is the Making Healthcare Safer Report?
The Making Healthcare Safer Report represents an ef…
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psnet.ahrq.gov/node/33567/psn-pdf
June 15, 2024 - Handoffs
June 15, 2024
Handoffs and Signouts. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/handoffs
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Backgroun…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
November 01, 2003 - Spotlight Case [MONTH] 2003
Spotlight Case November 2003
The Missing Suction Tip
Source and Credits
This presentation is based on the Nov. 2003
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Eric J. Thomas, MD,…