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  1. Leadership Role in Improving Safety | PSNet

    psnet.ahrq.gov/primer/leadership-role-improving-safety
    September 15, 2024 - Leadership Role in Improving Safety Citation Text: Leadership Role in Improving Safety. 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 Endno…

  2. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy | PSNet

    psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
    March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy Citation Text: Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…

  3. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet

    psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
    September 30, 2020 - SPOTLIGHT CASE Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Citation Text: Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…

  4. Retained Surgical Items: Causation and Prevention | PSNet

    psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
    January 04, 2024 - This process includes the management of items that may not have been specifically “counted” but which

  5. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet

    psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
    January 29, 2021 - patient’s abdominal signs and symptoms, the differential diagnosis for abdominal distention and diarrhea includes

  6. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing | PSNet

    psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
    August 21, 2005 - prophylactic dose  The AHS provided at the time of discharge plays a crucial role in patient education as it includes

  7. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. | PSNet

    psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
    July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. Citation Text: Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.. PSNet [internet]. Rockville (MD): A…

  8. Missed Opportunities for Suicide Risk Assessment | PSNet

    psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
    September 27, 2023 - Such patients require treatment planning that takes a long-term perspective that includes prevention

  9. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? | PSNet

    psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
    March 31, 2021 - Fasciitis’ (LRINEC) score is a risk stratification score to help providers identify potential NSTIs; it includes

  10. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet

    psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
    September 25, 2019 - analytic, and post-analytic phases. 1 The most common source of error is the pre-analytic phase , which includes

  11. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. | PSNet

    psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
    April 27, 2022 - Management of Intraoperative Bleeding The management of intraoperative bleeding includes two main considerations

  12. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes | PSNet

    psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
    April 10, 2024 - pandemic. 24,25 To assist NHs, the CDC has produced online training for Infection Preventionists that includes … not yet taken advantage of this training, endorsed by trade organizations. 62 The online training includes

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33567/psn-pdf
    June 15, 2024 - Handoffs June 15, 2024 Handoffs and Signouts. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/handoffs 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 safety field. Last reviewed in 2024. Backgroun…

  14. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls | PSNet

    psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
    December 18, 2024 - Now, Epic includes Fall TIPS as their standard content so that any hospital with Epic can access it.

  15. The Ongoing Journey to Prevent Patient Falls | PSNet

    psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
    December 18, 2024 - Now, Epic includes Fall TIPS as their standard content so that any hospital with Epic can access it.

  16. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-471
    December 31, 2024 - January 22, 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, report…

  17. Missed CANDOR Implementation Opportunities. | PSNet

    psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
    November 11, 2020 - Initiate the resolution process, which includes implementing patient safety processes to improve care

  18. What Have We Learned About Safe Inpatient Handovers? | PSNet

    psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
    March 01, 2011 - Researchers at Vanderbilt University have developed a higher intensity model of handover training, which includes … Well, certainly admission, which includes things like transfer from EMS [emergency medical services]

  19. Acute Care Admission of the Behavioral Health Patient | PSNet

    psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
    July 19, 2023 - Acute Care Admission of the Behavioral Health Patient Citation Text: Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: …

  20. The Impact of Communication on Medication Errors | PSNet

    psnet.ahrq.gov/web-mm/impact-communication-medication-errors
    August 01, 2009 - The goal of this process is to provide the patient with an accurate list that includes all of their medications
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