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psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
April 17, 2025 - The framework includes assessing whether systems are prepared for change, identifying leaders, and establishing
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - Stage III includes the development of sensory abnormalities, motor weakness, and bowel or bladder dysfunction
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psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
April 17, 2025 - Breadcrumb
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Interdisciplinary teamwork
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…
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psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
October 31, 2023 - To achieve improved workforce safety, organizations should start with a systems approach, which includes
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - needle access of the trachea followed by placement of a guidewire and dilation. 3 The procedure now includes
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psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
October 01, 2004 - whether of single-discipline crews or combined-teams, is heavily teamwork oriented
Teamwork includes
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psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - to provide education to prescribers that will improve the care of patients who use opioids and that includes
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - establish a pharmacy-directed anticoagulation dosing service on a 24-hours-a-day, 7-days-a-week basis that includes
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - decrease adverse events and medical errors. 17,18 I-PASS, for example, is a widely adopted program that includes
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psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
November 13, 2024 - Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area
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June 12, 2020
Innovation
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - To prevent falls, interventions must be tailored to patient-specific risk factors.( 10 ) Table 3 includes
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psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - Martin, MD, FNCS and Kiarash Shahlaie, MD, PhD, FAANS, FCNS Initial evaluation for brain injury often includes
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psnet.ahrq.gov/periodic-issue/periodic-issue-469
December 31, 2024 - January 8, 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…
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Medication Errors and Adverse Drug Events
Citation Text:
Medication Errors and Adverse Drug Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination
Citation Text:
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - Rescue Improvement Conference Innovation Summary
July 23, 2024
https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
Summary
The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure
to rescue with a particular focus on communication and com…
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psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - Medication Errors and Adverse Drug Events
December 15, 2024
Medication Errors and Adverse Drug Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect cu…
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
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July 23, 2024
View more articles from the same authors.
Innovation
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - The functional exam includes assessment of motor function, sensation, range of motion, and tendon integrity
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - SPOTLIGHT CASE
Dangerous Dialysis
Citation Text:
Holley JL. Dangerous Dialysis . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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