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2721. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33755/psn-pdf
      September 01, 2013 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety September 1, 2013 Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/what-weve-learned-ab…

2722. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33780/psn-pdf
      July 01, 2015 - Safety and Medical Education January 1, 2014 Ranji SR. Safety and Medical Education. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/safety-and-medical-education Annual Perspective 2014 As the patient safety field has grown, so too has the appreciation for the need to improve safety in medical educatio…

2723. Introducing the Redesigned AHRQ Patient Safety Network | PSNet
      psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
      December 01, 2005 - Introducing the Redesigned AHRQ Patient Safety Network Robert M. Wachter, MD | November 1, 2015  View more articles from the same authors. Citation Text: Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. Rockville (MD): Agency f…

2724. Second Victims: Support for Clinicians Involved in Errors and Adverse Events | PSNet
      psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
      December 15, 2024 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events Citation Text: Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cit…

2725. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50699/psn-pdf
      November 26, 2019 - Patient Safety in Frail Older Patients November 26, 2019 Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients Background Older patients are at a particular risk of experiencing a patient safety event. Stud…

2726. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33851/psn-pdf
      January 01, 2017 - The Weekend Effect January 1, 2017 Ranji SR. The Weekend Effect. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/weekend-effect Annual Perspective 2017 Introduction Anyone who has spent time in a hospital as a patient or staff member may recognize that the availability of services and personnel can va…

2727. Misconnection Leading to Arterial Thrombosis | PSNet
      psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
      January 29, 2021 - Misconnection Leading to Arterial Thrombosis Citation Text: Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bib…

2728. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. | PSNet
      psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
      March 03, 2021 - SPOTLIGHT CASE Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. Citation Text: Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…

2729. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
      February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…

2730. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49510/psn-pdf
      May 01, 2006 - Cups of Error May 1, 2006 Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/cups-error The Case An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered from dementia, he remained alert and oriented with only mild short-term memory…

2731. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
      August 01, 2015 - PowerPoint Presentation Spotlight Privacy or Safety? 1 This presentation is based on the July/August 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John D. Halamka, MD, MS, Beth Israel Deaconess Medical Center; and Deven McGraw, JD, MPH, LLM…

2732. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33812/psn-pdf
      August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD August 1, 2016 In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd Editor's note: Dr. Perea-Pérez is Director de la Escuela de Medicina Legal y For…

2733. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33579/psn-pdf
      September 15, 2024 - Systems Approach September 15, 2024 Systems Approach. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/systems-approach 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 …

2734. Measuring and Responding to Deaths From Medical Errors | PSNet
      psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
      April 01, 2008 - Annual Perspective Measuring and Responding to Deaths From Medical Errors Sumant Ranji, MD | March 22, 2016  View more articles from the same authors. Citation Text: Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. Rockville…

2735. Strategies and Approaches for Investigating Patient Safety Events | PSNet
      psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
      March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events Citation Text: Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…

2736. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866841/psn-pdf
      September 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary September 23, 2024 https://psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and- intervention-innovation Summary UNC Health is a nonprofit healthcare system of more than 500 clinics and…

2737. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866395/psn-pdf
      July 23, 2024 - Rescue Improvement Conference Innovation Summary July 23, 2024 https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary Summary The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure to rescue with a particular focus on communication and com…

2738. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866217/psn-pdf
      July 10, 2024 - In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives July 10, 2024 Helwig A, Sousane Z, Mossburg S. In Conversation With..Amy Helwig about Health Plan Patient Safety Initiatives. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patie…

2739. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
      August 01, 2009 - Spotlight Case July 2008 Spotlight Case Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care * Source and Credits This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME/CEU credit is available Commentary by: …

2740. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33601/psn-pdf
      December 15, 2024 - Electronic Health Records December 15, 2024 Electronic Health Records. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/electronic-health-records 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 safet…