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  1. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
    May 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case May 2004 Too Tight Control: The Risks of Intensive Insulin Therapy Source and Credits This presentation is based on the May 2004 AHRQ WebM&M Spotlight Case in Medicine CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Comm…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49507/psn-pdf
    April 01, 2006 - Is the "Surgical Personality" a Threat to Patient Safety? April 1, 2006 Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety? PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety Case Objectives Describe the myth of the "surgical personality" Identify featu…

  3. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety | PSNet

    psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
    March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety Sara J. Singer, MBA, PhD | September 1, 2013  View more articles from the same authors. Citation Text: Singer SJ. What We've Learned About Leveraging Leadership a…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33825/psn-pdf
    January 01, 2017 - Rethinking Root Cause Analysis January 1, 2016 Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis Annual Perspective 2016 Introduction Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33779/psn-pdf
    March 01, 2015 - Handoffs and Transitions January 22, 2014 Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/handoffs-and-transitions Annual Perspective 2014 Despite recent efforts to promote clinical integration, the United States health care system remains highly fragmented. From it…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73104/psn-pdf
    January 04, 2021 - AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety March 30, 2021 Stocking JC, Sandrock C, Fitall E, et al. AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact…

  7. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia | PSNet

    psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
    January 29, 2021 - Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia Citation Text: Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852807/psn-pdf
    August 30, 2023 - Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia August 30, 2023 Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73549/psn-pdf
    July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. July 28, 2021 Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty The Case A 61-year-old male patient weighing 57…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49726/psn-pdf
    March 01, 2015 - Two Wrongs Don't Make a Right (Kidney) March 1, 2015 DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney Case Objectives Review the current definition of wrong-site surgery. Describe the incidence of wrong-site surgery, and the…

  11. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
    January 01, 2020 - Spotlight Spotlight Discharged with IV antibiotics: When issues arise, who manages the complications? Source and Credits • This presentation is based on the February 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Monica Donnel…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33582/psn-pdf
    September 15, 2024 - Detection of Safety Hazards September 15, 2024 Detection of Safety Hazards. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/detection-safety-hazards 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 s…

  13. Electronic Health Records | PSNet

    psnet.ahrq.gov/primer/electronic-health-records
    March 15, 2025 - Electronic Health Records Citation Text: Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

  14. The Weekend Effect | PSNet

    psnet.ahrq.gov/perspective/weekend-effect
    April 01, 2008 - Annual Perspective The Weekend Effect Sumant Ranji, MD | January 1, 2017  View more articles from the same authors. Citation Text: Ranji SR. The Weekend Effect. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Hea…

  15. Detection of Safety Hazards | PSNet

    psnet.ahrq.gov/primer/detection-safety-hazards
    March 30, 2022 - Detection of Safety Hazards Citation Text: Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…

  16. Systems Approach | PSNet

    psnet.ahrq.gov/primer/systems-approach
    June 15, 2024 - Systems Approach Citation Text: Systems Approach. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downl…

  17. Rescue Improvement Conference Innovation Summary | PSNet

    psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
    September 23, 2024 - Rescue Improvement Conference Innovation Summary Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 23, 2024 View more articles from the same authors. Innovation Contact …

  18. System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary | PSNet

    psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-intervention-innovation
    July 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL September 23, 2024 View more articles from the same…

  19. Cups of Error | PSNet

    psnet.ahrq.gov/web-mm/cups-error
    January 12, 2011 - Cups of Error Citation Text: Blegen MA, Pepper GA. Cups of Error. 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 RIS…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840255/psn-pdf
    November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions November 16, 2022 Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions . PSNet [internet]. 2022. https://psnet.ahrq.gov/perspecti…
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