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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60328/psn-pdf
    May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression May 27, 2020 Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory- …
  2. psnet.ahrq.gov/perspective/patient-safety-primary-care
    January 31, 2020 - Annual Perspective Patient Safety in Primary Care February 21, 2020  View more articles from the same authors. Citation Text: Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60977/psn-pdf
    January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication September 30, 2020 Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication The Case A 65-year-old woman co…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33601/psn-pdf
    December 15, 2024 - Electronic Health Records December 15, 2024 Electronic Health Records. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/electronic-health-records 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…
  5. psnet.ahrq.gov/continuing-education
    February 26, 2025 - Continuing Education What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…
  6. psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…
  7. psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
    January 31, 2024 - Unseen Perils of Urinary Catheters Citation Text: Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar Bib…
  8. psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
    May 16, 2022 - Patients selected for M2B services  may benefit from a formalized process that includes sending prescriptions
  9. psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
    December 14, 2022 - Typically, a Safety-I evaluation includes asking the questions, “What do we need to do to stop this from
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847934/psn-pdf
    April 26, 2023 - Patient Safety Indicators April 26, 2023 Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/patient-safety-indicators Background Over the past 25 years, policymakers and providers, payers, and purchasers of health care have increasingly focused attention on pati…
  11. psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
    September 29, 2021 - SPOTLIGHT CASE Intraosseous Line Extravasation in a Pediatric Trauma Patient Citation Text: Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
  12. psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
    May 26, 2021 - SPOTLIGHT CASE Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression Citation Text: Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
  13. psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
    June 24, 2020 - Medication-related CDS includes alerts that advise prescribers on dosing, allergies, drug interactions
  14. psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
    December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication Citation Text: Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cit…
  15. psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
    November 01, 2016 - primary care physicians within our health system 24 hours after hospital discharge.( 28 ) This document includes
  16. psnet.ahrq.gov/web-mm/what-happened-telemetry
    January 18, 2012 - *At a minimum, includes bedside nurses, clinical nurse specialists or educators, cardiologists, hospitalists
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33564/psn-pdf
    March 15, 2025 - Computerized Provider Order Entry March 15, 2025 Computerized Provider Order Entry. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/computerized-provider-order-entry PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice…
  18. psnet.ahrq.gov/innovation/implementing-watcher-program-improve-timeliness-recognition-deterioration-hospitalized
    June 30, 2021 - EMERGING INNOVATIONS Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Citation Text: Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Evans S, Green A, Roberson A, et al. …
  19. psnet.ahrq.gov/perspective/medias-role-patient-safety
    April 27, 2022 - the Quality Chasm report. 7  Here the IOM doesn’t include references to actual patients but rather includes
  20. psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
    October 31, 2023 - SPOTLIGHT CASE Robotic Surgery: Risks vs. Rewards Citation Text: Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Googl…

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