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4841. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33673/psn-pdf
      September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety September 1, 2008 Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety Perspective Medication safety in hospitals depends on the successful execu…

4842. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49538/psn-pdf
      June 01, 2007 - Abnormal Volunteer Results June 1, 2007 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results The Case A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent magnetic resonance imaging (MRI) of her abdo…

4843. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49436/psn-pdf
      February 26, 2004 - Transfusion "Slip" February 1, 2004 Kaplan HS. Transfusion "Slip". PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/transfusion-slip The Case A married couple, Mr. and Mrs. M, was brought to the emergency department (ED) of a Level 1 trauma center after a half-ton truck that had skidded out of control struck…

4844. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49604/psn-pdf
      June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…

4845. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33665/psn-pdf
      March 01, 2008 - Creation of a Medical Procedure Service to Improve Patient Safety March 1, 2008 Smith CC, CHuang G. Creation of a Medical Procedure Service to Improve Patient Safety. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety Perspective Introduction and …

4846. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865658/psn-pdf
      April 24, 2024 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents? April 24, 2024 Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents? PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/managing-care-challenges-group-…

4847. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50859/psn-pdf
      January 31, 2020 - In Conversation With... David Gruen, MD January 31, 2020 In Conversation With.. David Gruen, MD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-david-gruen-md Editor’s note: David R. Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson Health and is a thought leader and…

4848. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74253/psn-pdf
      January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic January 12, 2022 Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/patient…

4849. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49703/psn-pdf
      March 01, 2014 - After-Visit Confusion March 1, 2014 Ventres W. After-Visit Confusion. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/after-visit-confusion The Case An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white spots near her tongue. The patient's mother accompanied her …

4850. Critical Opportunity Lost | PSNet
      psnet.ahrq.gov/web-mm/critical-opportunity-lost
      February 17, 2017 - Critical Opportunity Lost Citation Text: Genzen JR, Signorelli HN. Critical Opportunity Lost. 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 EndNote 7 XML…

4851. Wrong-side Bedside Paravertebral Block: Preventing the Preventable | PSNet
      psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
      August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable Citation Text: Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy C…

4852. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49444/psn-pdf
      May 01, 2004 - Do Me a Favor May 1, 2004 Williamson A. Do Me a Favor. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/do-me-favor The Case A 26-year-old gravida 4 para 1 woman reported that her last menstrual period was 5 weeks prior, and she had a positive home pregnancy test. With a history of one ectopic pregnancy, one…

4853. “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV) | PSNet
      psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
      February 26, 2025 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV) Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 30, 2021 Innovat…

4854. Collegiality vs. Competence | PSNet
      psnet.ahrq.gov/web-mm/collegiality-vs-competence
      August 28, 2024 - Collegiality vs. Competence Citation Text: Sagin T. Collegiality vs. Competence. 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 tagg…

4855. Check the Anesthesia Machine | PSNet
      psnet.ahrq.gov/web-mm/check-anesthesia-machine
      August 01, 2006 - Check the Anesthesia Machine Citation Text: Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

4856. Safety in the Retail Pharmacy | PSNet
      psnet.ahrq.gov/perspective/safety-retail-pharmacy
      May 11, 2016 - Safety in the Retail Pharmacy Michelle A. Chui, PharmD, PhD | October 1, 2018  View more articles from the same authors. Citation Text: Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departme…

4857. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/74277
      January 01, 2021 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Medication/Drug Errors Curated Library Primers Medication Administration Errors Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March, 12 2021 Medication administration errors are a persistent patient saf…

4858. Handoffs and Transitions | PSNet
      psnet.ahrq.gov/perspective/handoffs-and-transitions
      February 01, 2007 - Annual Perspective Handoffs and Transitions Niraj Sehgal, MD, MPH | January 22, 2014  View more articles from the same authors. Citation Text: Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

4859. "Superficial" Report Leads to "Deep" Problem | PSNet
      psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
      July 01, 2012 - "Superficial" Report Leads to "Deep" Problem Citation Text: Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndN…

4860. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
      October 01, 2013 - PowerPoint Presentation Spotlight Case It's Sarah, not Stephen! 1 This presentation is based on the October 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Urmimala Sarkar, MD, MPH, University of California at San Francisco Editor, AHRQ WebM&…