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9521. PCA Overdose | PSNet
      psnet.ahrq.gov/web-mm/pca-overdose
      April 01, 2017 - PCA Overdose Citation Text: Doyle JD. PCA Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

9522. Weekly Resource | PSNet
      psnet.ahrq.gov/periodic-issue/weekly-resource
      March 25, 2025 - March 12, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports,…

9523. 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…

9524. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45840/psn-pdf
      February 08, 2017 - Implementation of the safety huddle. February 8, 2017 Kylor C, Napier T, Rephann A, et al. Implementation of the Safety Huddle. Crit Care Nurse. 2016;36(6):80- 82. https://psnet.ahrq.gov/issue/implementation-safety-huddle The safety huddle is becoming common within health care practice as a way to inform clinician…

9525. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841489/psn-pdf
      December 14, 2022 - Rise to Health Coalition. December 14, 2022 Boston, MA; Institute for Healthcare Improvement: December 2022. https://psnet.ahrq.gov/issue/rise-health-coalition Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative for collective work to address four areas of e…

9526. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35097/psn-pdf
      June 22, 2009 - Impact of duty hour limits on resident training in otolaryngology. June 22, 2009 Reiter ER, Wong DR. Impact of duty hour limits on resident training in otolaryngology. Laryngoscope. 2005;115(5):773-9. https://psnet.ahrq.gov/issue/impact-duty-hour-limits-resident-training-otolaryngology The authors surveyed reside…

9527. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41165/psn-pdf
      December 08, 2016 - IHI Open School Patient Safety Curriculum December 8, 2016 Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/patient-safety-curriculum-2nd-edition There is a documented interest in postgraduate professional education that enables practicing clinicians to improve the safety of their actions and beh…

9528. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42005/psn-pdf
      January 30, 2013 - Infusing fun into quality and safety initiatives. January 30, 2013 Foulk KC, Tocydlowski P, Snow TM, et al. Infusing fun into quality and safety initiatives. Nursing (Brux). 2012;42(11):14-16. doi:10.1097/01.NURSE.0000421386.36112.a9. https://psnet.ahrq.gov/issue/infusing-fun-quality-and-safety-initiatives Nursing…

9529. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43454/psn-pdf
      November 20, 2015 - Training in quality and safety: the current landscape. November 20, 2015 Karasick AS, Nash DB. Training in quality and safety: the current landscape. Am J Med Qual. 2015;30(6):526-38. doi:10.1177/1062860614544194. https://psnet.ahrq.gov/issue/training-quality-and-safety-current-landscape This commentary offers inf…

9530. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841198/psn-pdf
      December 07, 2022 - Technology, Education and Safety. December 7, 2022 Arna D, ed. Curr Opin Anaesthesiol. 2022;35(6):710-737. https://psnet.ahrq.gov/issue/technology-education-and-safety-1 Safety challenges in anesthesiology and perioperative care are high-risk situations. This segment of a reoccurring special section covers strateg…

9531. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42131/psn-pdf
      March 20, 2013 - What surgeons leave behind costs some patients dearly. March 20, 2013 Eisler P. https://psnet.ahrq.gov/issue/what-surgeons-leave-behind-costs-some-patients-dearly This newspaper article describes two incidents of retained surgical items and discusses the technological solutions to prevent them. https://psnet.ahrq…

9532. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45287/psn-pdf
      August 03, 2016 - Mistakes We Make in Dialysis. August 3, 2016 Rodby RA, Perazella MA, eds. Semin Dial. 2016;29(4):253-328. https://psnet.ahrq.gov/issue/mistakes-we-make-dialysis Insufficient application of new evidence to inform treatment decisions can hinder safe care delivery. Articles in this special issue explore common renal …

9533. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44583/psn-pdf
      February 17, 2016 - Root Cause Analysis Playbook. February 17, 2016 Chicago, IL: American Society for Healthcare Risk Management; 2015. https://psnet.ahrq.gov/issue/root-cause-analysis-playbook Risk management has recently focused on organization-wide improvement in patient safety. This publication discusses root cause analysis metho…

9534. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/856639/psn-pdf
      November 29, 2023 - Impact Wellbeing. November 29, 2023 National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/impact-wellbeing Clinician burnout has become a major concern for both healthcare workforce and patient safety. This portal provides access to too…

9535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39982/psn-pdf
      January 17, 2012 - Hand-off Communications. January 17, 2012 DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. https://psnet.ahrq.gov/issue/hand-communications The Joint Commission Center for Transforming Hea…

9536. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35441/psn-pdf
      September 18, 2009 - Bridging the communication gap in the operating room with medical team training. September 18, 2009 Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5):770-4. https://psnet.ahrq.gov/issue/bridging-communication-gap-operating-r…

9537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35318/psn-pdf
      September 20, 2024 - AHRQ Quality Indicators. September 20, 2024 Agency for Healthcare Research and Quality https://psnet.ahrq.gov/issue/ahrq-quality-indicators The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) represent quality measures that make use of a hospital's available administrative data to inform…

9538. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49583/psn-pdf
      April 01, 2009 - Eptifibatide Epilogue April 1, 2009 Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue The Case A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute coronary syndrome. Serial testing for mark…

9539. Privacy Gone Awry | PSNet
      psnet.ahrq.gov/web-mm/privacy-gone-awry
      February 24, 2011 - Privacy Gone Awry Citation Text: Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…

9540. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49872/psn-pdf
      August 08, 2019 - Spinal Epidural Abscess August 8, 2019 Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess The Case A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a few days of progressive low back pain. She…