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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866165/psn-pdf
    June 19, 2024 - Actions for mitigating the negative effects of patient participation in patient safety: a qualitative study. June 19, 2024 Van der Voorden M, Franx A, Ahaus K. Actions for mitigating the negative effects of patient participation in patient safety: a qualitative study. BMC Health Serv Res. 2024;24(1):700. doi:10.118…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841474/psn-pdf
    January 01, 2023 - Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems. December 14, 2022 Childs E, Tano CA, Mikosz CA, et al. Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems. Jt Comm J Qual Patient Saf. 2023;49(1):26…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34769/psn-pdf
    March 28, 2005 - The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. March 28, 2005 Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN 9780226851754. https://psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa A model of root cause analysis on a syste…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849134/psn-pdf
    May 17, 2023 - Adverse patient safety events during the COVID epidemic. May 17, 2023 Yackel EE, Knowles RS, Jones CM, et al. Adverse patient safety events during the COVID epidemic. J Patient Saf. 2023;19(5):340-345. doi:10.1097/pts.0000000000001129. https://psnet.ahrq.gov/issue/adverse-patient-safety-events-during-covid-epidemic…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72724/psn-pdf
    February 10, 2021 - How satisfied are patients and surgeons with telemedicine in orthopaedic care during the COVID-19 pandemic? A systematic review and meta-analysis. February 10, 2021 Chaudhry H, Nadeem S, Mundi R. How Satisfied Are Patients and Surgeons with Telemedicine in Orthopaedic Care During the COVID-19 Pandemic? A Systemati…
  6. psnet.ahrq.gov/web-mm/e-prescribing-e-error
    February 03, 2021 - Improving patient safety by identifying side effects from introducing bar coding in medication administration
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837963/psn-pdf
    August 31, 2022 - Identifying Risks to Patient Safety The PCP, gastroenterologist, and endocrinologist did not fully consider
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849679/psn-pdf
    June 28, 2023 - ventilator settings were applied, or the patient’s body habitus, but this information would be useful in identifying
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850450/psn-pdf
    June 14, 2023 - Call the clinic for additional background information …” Identifying the treating outpatient physician
  10. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
    October 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case October 2004 Thin Air Source and Credits This presentation is based on the Oct. 2004 AHRQ WebM&M Spotlight Case in Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: David M. Gaba, MD, Stanford Univer…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33559/psn-pdf
    December 15, 2024 - Medication Reconciliation December 15, 2024 Medication Reconciliation. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/medication-reconciliation 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…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49431/psn-pdf
    January 01, 2004 - Keys to detecting acute aortic dissection are a complete history (identifying the quality, severity,
  13. psnet.ahrq.gov/web-mm/all-history
    February 28, 2011 - These "ring downs" are necessarily brief, do not include identifying information (beyond patient age
  14. psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
    August 05, 2022 - mitigated through best practices in medication reconciliation , which is defined as the process of identifying
  15. psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
    March 31, 2021 - Identifying Risks to Patient Safety The PCP, gastroenterologist, and endocrinologist did not fully
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33715/psn-pdf
    July 01, 2011 - Becoming a Patient Safety Organization July 1, 2011 Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization Perspective While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49824/psn-pdf
    March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay March 1, 2018 O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay The Case A 35-year-old woman with no prior cardiac history calle…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49581/psn-pdf
    March 21, 2009 - Double Dosing, by the Rules March 21, 2009 Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/double-dosing-rules The Case A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was admitted to a medical unit during the night with wo…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49448/psn-pdf
    June 01, 2004 - Listen to the Family June 1, 2004 Campbell D. Listen to the Family. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/listen-family The Case Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The surgical resident examined the patient, an elderly woman with …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49598/psn-pdf
    February 01, 2010 - Medication Reconciliation Pitfalls February 1, 2010 Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls The Case A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was brought to the eme…

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