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2701. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33588/psn-pdf
      March 15, 2025 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events March 15, 2025 Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events PSNet primers are regu…

2702. In response to "Failure to Report" (March 2007) | PSNet
      psnet.ahrq.gov/perspective/response-failure-report-march-2007
      June 01, 2007 - In response to "Failure to Report" (March 2007) June 1, 2007  View more articles from the same authors. Citation Text: Paparella S, Vaida AJ, Spath P. In response to "Failure to Report" (March 2007). PSNet [internet]. Rockville (MD): Agency for Healthcare Research …

2703. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49738/psn-pdf
      August 21, 2015 - Privacy or Safety? August 21, 2015 Halamka JD, McGraw D. Privacy or Safety? PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/privacy-or-safety Case Objectives Understand that the HIPAA Omnibus Rule is an enabler of data sharing, not a barrier. Review common misconceptions about privacy rules. Understand the…

2704. Elopement | PSNet
      psnet.ahrq.gov/web-mm/elopement
      July 14, 2010 - SPOTLIGHT CASE Elopement Citation Text: Gerardi D. Elopement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

2705. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33583/psn-pdf
      March 01, 2023 - Simulation Training March 1, 2023 Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/simulation-training Originally published in 2014 by researchers at the University of California, San Francisco. Updated in March 2023, by Jennifer J. Edwards, MS, RN, CHSE…

2706. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33647/psn-pdf
      March 01, 2007 - The Role of the Patient in Improving Patient Safety March 1, 2007 Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/role-patient-improving-patient-safety Perspective Patients have three roles in improving patient safety: helping to ensure thei…

2707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33830/psn-pdf
      March 22, 2016 - Measuring and Responding to Deaths From Medical Errors March 22, 2016 Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors Annual Perspective 2016 The Prevalence of Deaths Due to Preventable Adve…

2708. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72616/psn-pdf
      December 22, 2020 - Adverse Events in Dentistry December 22, 2020 Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/adverse-events-dentistry Introduction Similar to many other healthcare settings, dentistry carries with it inherent patient safety risks. D…

2709. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33817/psn-pdf
      October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety October 1, 2016 Rajkomar A. Health Care Data Science for Quality Improvement and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety Perspective Background Ha…

2710. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836812/psn-pdf
      March 30, 2022 - Strategies and Approaches for Investigating Patient Safety Events March 30, 2022 Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events Background This primer provides a broad …

2711. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33777/psn-pdf
      January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care January 1, 2015 Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…

2712. Privacy or Safety? | PSNet
      psnet.ahrq.gov/web-mm/privacy-or-safety
      December 01, 2011 - SPOTLIGHT CASE Privacy or Safety? Citation Text: Halamka JD, McGraw D. Privacy or Safety?. 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 XML EndNo…

2713. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/838900/psn-pdf
      October 27, 2022 - Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. October 27, 2022 Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/fecal-contamination-…

2714. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
      January 01, 2022 - Spotlight Spotlight Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong Source and Credits • This presentation is based on the October 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary…

2715. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50754/psn-pdf
      December 18, 2019 - "Do You Want Everything Done?": Clarifying Code Status December 18, 2019 Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status Disclosure of Relevant Financial Relationships: As a p…

2716. Hospital-Acquired Diabetic Ketoacidosis. | PSNet
      psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
      October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis. Citation Text: Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bi…

2717. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851099/psn-pdf
      June 28, 2023 - Misconnection Leading to Arterial Thrombosis June 28, 2023 Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis The Case A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…

2718. Multifactorial Medication Mishap | PSNet
      psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
      September 01, 2016 - SPOTLIGHT CASE Multifactorial Medication Mishap Citation Text: Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNot…

2719. AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety | PSNet
      psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
      August 31, 2020 - Annual Perspective AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety March 30, 2021  View more articles from the same authors. Citation Text: Stocking JC, Sandrock C, Fitall E, et al. AHRQ PSNet Annual Perspective: Impact of the…

2720. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
      May 01, 2013 - Spotlight Case July 2008 Spotlight Case Right Regimen, Wrong Cancer: Patient Catches Medical Error * * Source and Credits This presentation is based on the May 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Joseph O. Jacobson, MD, MSc…