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psnet.ahrq.gov/node/49729/psn-pdf
April 01, 2015 - We do know that there is a higher
incidence of AAD in men (65%) and with increasing age.(4)
Clinical
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - • Before this could happen, the patient developed increasing hypoxemia and
respiratory distress,
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psnet.ahrq.gov/web-mm/emergent-triage-miss
March 06, 2015 - March 15, 2017
10,000 good catches: increasing safety event reporting in a pediatric
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psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - psnet.ahrq.gov/issue/intervention-decrease-catheter-related-bloodstream-infections-icu
cranky—we've seen increasing
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psnet.ahrq.gov/node/49779/psn-pdf
January 01, 2017 - The care team identified that the patient had increasing restlessness and that the current order for
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - Nursing will
be of increasing importance, and they are the largest health care workforce we have, especially
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psnet.ahrq.gov/node/33839/psn-pdf
August 01, 2017 - So increasing it from 80 was just
not tenable.
RW: Understood.
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psnet.ahrq.gov/primer/duty-hours-and-patient-safety
June 15, 2024 - Duty Hours and Patient Safety
Citation Text:
Duty Hours and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
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psnet.ahrq.gov/node/49524/psn-pdf
November 01, 2006 - Secured But Not Always Safe
November 1, 2006
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/secured-not-always-safe
The Case
An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative
osteoarthritis. She received spinal …
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psnet.ahrq.gov/node/33753/psn-pdf
August 22, 2013 - Update on Safety Culture
August 22, 2013
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/update-safety-culture
Perspective
Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians
treat each other with r…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
December 01, 2014 - PowerPoint Presentation
Spotlight
A Stroke of Error
This presentation is based on the December 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…
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psnet.ahrq.gov/node/867804/psn-pdf
February 26, 2025 - Are We Safer Today?
February 26, 2025
Bates DW, Lee M, Mossburg SE. Are We Safer Today? PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/are-we-safer-today
In the 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (now the
National Academy of Medicine) drew on two lar…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
September 01, 2003 - Spotlight Case September 2003
Spotlight Case September 2003
Infant Paralyzed for Intubation Before Airway Materials Ready
Source and Credits
This presentation is based on the Sept. 2003 AHRQ WebM&M Spotlight Case in Pediatrics
See the full article at http://webmm.ahrq.gov
CME credit is available through the …
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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - Falling Between the Cracks in the Software
August 21, 2016
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-between-cracks-software
The Case
A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…
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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…
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psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
October 30, 2024 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration
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June 14, 2023
Innov…
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Around the Block
Citation Text:
Minichiello T. Around the Block. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - The Wrongful Resuscitation
Citation Text:
Teno JM. The Wrongful Resuscitation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
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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…
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psnet.ahrq.gov/node/33672/psn-pdf
September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH
September 1, 2008
In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
Editor's note: Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women's
Hospital and Assi…