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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47299/psn-pdf
    March 20, 2019 - Unintentionally retained guidewires: a descriptive study of 73 sentinel events. March 20, 2019 Steelman VM, Thenuwara K, Shaw C, et al. Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events. Jt Comm J Qual Saf. 2019;45(2):81-90. doi:10.1016/j.jcjq.2018.08.003. https://psnet.ahrq.gov/issue/…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43166/psn-pdf
    May 07, 2014 - Are med school grads prepared to practice medicine? May 7, 2014 Angus S, Vu R, Halvorsen AJ, et al. What skills should new internal medicine interns have in july? A national survey of internal medicine residency program directors. Academic medicine : journal of the Association of American Medical Colleges. 2014;89(…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41961/psn-pdf
    January 16, 2013 - Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. January 16, 2013 Williams SD, Phipps D, Ashcroft DM. Understanding the attitudes of hospital pharmacists to reporting medication incidents: a qualitative study. Res Social Adm Pharm. 2013;9(1):80-9. doi:10.1…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36895/psn-pdf
    March 10, 2011 - A systematic review of the performance characteristics of clinical event monitor signals used to detect adverse drug events in the hospital setting. March 10, 2011 Handler S, Altman RL, Perera S, et al. A systematic review of the performance characteristics of clinical event monitor signals used to detect adverse …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34808/psn-pdf
    February 18, 2011 - The high cost of low-frequency events: the anatomy and economics of surgical mishaps. February 18, 2011 Couch NP, Tilney NL, Rayner AA, et al. The high cost of low-frequency events: the anatomy and economics of surgical mishaps. N Engl J Med. 1981;304(11):634-7. https://psnet.ahrq.gov/issue/high-cost-low-frequency…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867190/psn-pdf
    November 20, 2024 - Misdiagnosis is dangerous. Help your doctor get it right. November 20, 2024 Terry K. Misdiagnosis is dangerous. Help your doctor get it right. WebMD. November 11, 2024; https://psnet.ahrq.gov/issue/misdiagnosis-dangerous-help-your-doctor-get-it-right Patients are partners in health care and can inform actions to id…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40945/psn-pdf
    November 23, 2011 - The nature and causes of unintended events reported at 10 internal medicine departments. November 23, 2011 Lubberding S, Zwaan L, Timmermans D, et al. The nature and causes of unintended events reported at 10 internal medicine departments. J Patient Saf. 2011;7(4):224-31. doi:10.1097/PTS.0b013e3182388f97. https://…

  8. Urine a Tough Position | PSNet

    psnet.ahrq.gov/web-mm/urine-tough-position
    January 01, 2009 - Urine a Tough Position Citation Text: Gandhi TK. Urine a Tough Position. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49695/psn-pdf
    October 01, 2013 - Finding Fault With the Default Alert October 1, 2013 Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/finding-fault-default-alert The Case A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital after experiencing …

  10. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
    March 01, 2011 - Spotlight Case July 2008 Spotlight Case March 2011 Volume Too Low: In and Out Pediatric Patient Safety * * Source and Credits This presentation is based on the March 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Marlene Miller, MD, MSc…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33659/psn-pdf
    October 01, 2007 - Making Just Culture a Reality: One Organization's Approach October 1, 2007 Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach Perspective We've all been there...something goes wrong,…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49727/psn-pdf
    March 01, 2015 - Critical Opportunity Lost March 1, 2015 Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/critical-opportunity-lost The Case A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She reported eating a heavy dinner the pre…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72624/psn-pdf
    January 05, 2021 - The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm January 5, 2021 https://psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework- reducing-inpatient-harm Summary Building on the company’s experience as a Hospital Engagement Network…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73412/psn-pdf
    August 01, 2022 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV) June 30, 2021 https://psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and- disclosure Summary The Behavioral Health Vital Signs (BHVS) screener i…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49771/psn-pdf
    July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49870/psn-pdf
    August 10, 2019 - Anemia and Delayed Colon Cancer Diagnosis August 10, 2019 Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis Case Objectives Describe the initial evaluation for iron deficiency anemia in elderly adults…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73642/psn-pdf
    August 25, 2021 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021 Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect- unexpected …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49744/psn-pdf
    October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy October 1, 2015 Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49855/psn-pdf
    March 01, 2019 - Which Line: Ordering Provider or Proceduralist? March 1, 2019 Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading to adverse…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854391/psn-pdf
    October 11, 2023 - Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving Patient Safety. October 11, 2023 Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, France: OECD Publishing; 2023. OECD Health Working Papers, No. 159. https://psnet.ahrq.gov/issue/patient-engagement-patient-safe…
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