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  1. psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
    June 28, 2023 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January 31, 2024 Innovation Contact …
  2. 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. Copy Citation Format: Googl…
  3. Psn-Pdf (pdf file)

    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…
  4. 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…
  5. Psn-Pdf (pdf file)

    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 …
  6. Psn-Pdf (pdf file)

    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 …
  7. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
  8. Spotlight Case (ppt file)

    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…
  9. 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 …
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. 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…
  14. Psn-Pdf (pdf file)

    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…
  15. 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…
  16. 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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. 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,…

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