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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33854/psn-pdf
    March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety March 1, 2018 Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety Perspective Errors in hospitals remain a major cause of death.(1…
  2. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
    November 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case November 2005 Reconciling Doses Source and Credits This presentation is based on the November 2005 Spotlight Case in Emergency Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Frank Federico, RPh,…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33641/psn-pdf
    November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again November 1, 2006 Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again Perspective Certain phrases ar…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50615/psn-pdf
    October 30, 2019 - Misidentifying the Unidentified – John Doe and the EHR October 30, 2019 Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr The Case  Two male patients of similar age arrived at the same …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33755/psn-pdf
    September 01, 2013 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety September 1, 2013 Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49421/psn-pdf
    October 01, 2003 - Urine a Tough Position October 1, 2003 Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/urine-tough-position The Case A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although she did not want to have a baby at that time, she sta…
  7. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
    January 01, 2015 - Spotlight Case [MONTH] 2003 Spotlight Case February 2007 The ‘Customer’ Is Always Right Source and Credits This presentation is based on the February 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Niraj L. Sehgal,…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49416/psn-pdf
    September 01, 2003 - Check the Bags September 1, 2003 Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-bags The Case A 50-year-old man with new atrial fibrillation was placed on a diltiazem drip in the emergency department for rate control. After arriving at the cardiac care unit (CCU…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49511/psn-pdf
    May 01, 2006 - Citrate Mix-Up May 1, 2006 Weber RJ. Citrate Mix-Up. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/citrate-mix The Case A 36-year-old woman with multiple sclerosis, diabetes, and chronic renal failure was transferred from a skilled nursing facility (SNF) to the hospital for treatment of an infection. On a…
  10. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
    May 01, 2009 - Spotlight Case July 2008 Spotlight Case Delirium or Dementia? Source and Credits This presentation is based on the May 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James L. Rudolph, MD, SM Editor, AHRQ WebM&M: Robert Wachter, MD Sp…
  11. psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
    December 01, 2006 - change that results Existing culture remains Resident teams use a computer generated list that includes
  12. psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
    December 01, 2006 - change that results Existing culture remains Resident teams use a computer generated list that includes
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33857/psn-pdf
    July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP July 1, 2012 In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0 Editor's note: Dr. Blumenthal is President of the Commonwealth Fund and served as the National Coordinator …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867850/psn-pdf
    February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/persp…
  15. psnet.ahrq.gov/perspective/conversation-lucian-leape-md
    June 12, 2019 - In Conversation With… Lucian Leape, MD April 1, 2015  Citation Text: In Conversation With… Lucian Leape, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865429/psn-pdf
    April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery April 24, 2024 Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…
  17. psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
    September 01, 2017 - adequate data for further improvement—for instance, a daily monitoring report to the charge nurse that includes … Joint Commission recommends that each organization's: "process for effective hand off communication includes … Clinical content Includes everything on the data-information-knowledge continuum stored in the … Human–computer interface Enables unrelated entities to interact with the system and includes aspects
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33707/psn-pdf
    February 01, 2011 - Research and QI projects Course content includes (but not limited to): systems failure and medical … interventions in CQI framework and designing additional or new interventions Duration: 6 days Course includes … Duration: 20 days Course includes lectures from national experts and completion and reporting of … science, support to attend meetings, and bonuses for good performance Duration: 8 hours Program includes
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49732/psn-pdf
    May 01, 2015 - , sepsis always involves activation of the host inflammatory response and, in more serious states, includes … updated in 2013 by the Surviving Sepsis Campaign (SSC) and endorsed by multiple medical societies, includes … timely manner.(4) Based on an initial protocol performed by Rivers and colleagues (5), the bundle includes … UCSF Bundle Compliance and Mortality (Includes All Adult Inpatients and the Emergency Department).
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
    May 01, 2015 - initiated by an infection Sepsis always involves activation of the host inflammatory response and often includes … treatment with the "resuscitation bundle" The bundle, updated in the Surviving Sepsis Campaign in 2013, includes … www.ncbi.nlm.nih.gov/pubmed/23353941 12 Resuscitation Bundle Based on a NEJM study published in 2001, the bundle includes

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