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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49709/psn-pdf
    May 01, 2014 - Raise the Bar May 1, 2014 Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/raise-bar The Case A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The patient was seen and evaluated by an anesthesiologist who was new to the cente…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49836/psn-pdf
    July 01, 2018 - Primary Workaround, Secondary Complication July 1, 2018 Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication The Case A young adult with a progressive neurological disorder presented to a hospital emerg…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49726/psn-pdf
    March 01, 2015 - Two Wrongs Don't Make a Right (Kidney) March 1, 2015 DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney Case Objectives Review the current definition of wrong-site surgery. Describe the incidence of wrong-site surgery, and the…
  4. psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
    September 27, 2023 - Timely diagnosis of esophageal perforation Citation Text: Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43265/psn-pdf
    February 15, 2024 - Five Medication Safety Tips for Older Adults. February 15, 2024 FDA Consumer Health Information. Silver Spring, MD: US Food and Drug Administration; February 15, 2024. https://psnet.ahrq.gov/issue/five-medication-safety-tips-older-adults Highlighting how aging affects medication absorption that may lead to complic…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50771/psn-pdf
    May 29, 2024 - AHRQ Health Literacy Universal Precautions Toolkit. 3rd edition. May 29, 2024 Brach C, ed. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Publication No. 15-0023-EF. https://psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-2nd-edition The AHRQ Health Literacy Un…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34128/psn-pdf
    December 23, 2016 - Patient controlled analgesia by proxy. December 23, 2016 Patient controlled analgesia by proxy. Sentinel Event Alert. 2004;33(33):1-2. https://psnet.ahrq.gov/issue/patient-controlled-analgesia-proxy Patient-controlled analgesia (PCA) is a recognized method of controlling pain when administered by credentialed prac…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42495/psn-pdf
    November 18, 2013 - The role of technology in clinician-to-clinician communication. November 18, 2013 McElroy LM, Ladner DP, Holl JL. The role of technology in clinician-to-clinician communication. BMJ Qual Saf. 2013;22(12):981-3. doi:10.1136/bmjqs-2013-002191. https://psnet.ahrq.gov/issue/role-technology-clinician-clinician-communic…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43422/psn-pdf
    August 06, 2014 - Core Entrustable Professional Activities for Entering Residency. August 6, 2014 Washington, DC: Association of American Medical Colleges; 2014. https://psnet.ahrq.gov/issue/core-entrustable-professional-activities-entering-residency Studies have revealed a gap between what residents are expected to know and how pr…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837813/psn-pdf
    January 21, 2021 - Recognizing Excellence in Diagnosis. January 21, 2021 The Leapfrog Group. https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise to be successful. This collaborative initiative will initially dev…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72862/psn-pdf
    March 17, 2021 - Cutaneous Procedures Adverse Events Reporting (CAPER). March 17, 2021 The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology. https://psnet.ahrq.gov/issue/cutaneous-procedures-adverse-events-reporting-caper Voluntary reporting systems collect adverse ev…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39180/psn-pdf
    December 16, 2009 - Description of inpatient medication management using cognitive work analysis. December 16, 2009 Pingenot AA, Shanteau J, Sengstacke LTCDN. Description of inpatient medication management using cognitive work analysis. Comput Inform Nurs. 2009;27(6):379-92. doi:10.1097/NCN.0b013e3181bcad2f. https://psnet.ahrq.gov/is…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37021/psn-pdf
    February 17, 2011 - Disclosing harmful medical errors to patients. February 17, 2011 Gallagher TH, Studdert DM, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med. 2007;356(26):2713-9. https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients In this article, the authors review disclosure standards,…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37034/psn-pdf
    March 10, 2011 - Adoption of order entry with decision support for chronic care by physician organizations. March 10, 2011 Simon JS, Rundall TG, Shortell SM. Adoption of order entry with decision support for chronic care by physician organizations. J Am Med Inform Assoc. 2007;14(4):432-9. https://psnet.ahrq.gov/issue/adoption-orde…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35384/psn-pdf
    January 02, 2017 - New York-Presbyterian Hospital: translating innovation into practice. January 2, 2017 Johnson T, Currie G, Keill P, et al. NewYork-Presbyterian Hospital: translating innovation into practice. Jt Comm J Qual Patient Saf. 2005;31(10):554-60. https://psnet.ahrq.gov/issue/new-york-presbyterian-hospital-translating-inn…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38318/psn-pdf
    March 10, 2011 - Tiering drug–drug interaction alerts by severity increases compliance rates. March 10, 2011 Paterno MD, Maviglia SM, Gorman PN, et al. Tiering drug-drug interaction alerts by severity increases compliance rates. J Am Med Inform Assoc. 2009;16(1):40-6. doi:10.1197/jamia.M2808. https://psnet.ahrq.gov/issue/tiering-d…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48154/psn-pdf
    July 31, 2019 - Learn Not Blame. July 31, 2019 Doctors' Association UK. https://psnet.ahrq.gov/issue/learn-not-blame This website provides information about a National Health Service (NHS) campaign to shift response to errors from blame to an approach that embraces fairness, openness, learning, and patient and health care profes…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35283/psn-pdf
    July 14, 2010 - Hospitalists as emerging leaders in patient safety: targeting a few to affect many. July 14, 2010 Flanders SA, Kaufman SR, Saint S, et al. Hospitalists as emerging leaders in patient safety: targeting a few to affect many. J Patient Saf. 2005;1(2):78-82. doi:10.1097/pts.0b013e31819751f2. https://psnet.ahrq.gov/iss…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36885/psn-pdf
    March 10, 2011 - Communication outcomes of critical imaging results in a computerized notification system. March 10, 2011 Singh H, Arora HS, Vij MS, et al. Communication outcomes of critical imaging results in a computerized notification system. J Am Med Inform Assoc. 2007;14(4):459-66. https://psnet.ahrq.gov/issue/communication-o…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854642/psn-pdf
    October 18, 2023 - Cybersecurity for the Clinician. October 18, 2023 Chicago, IL: American Medical Association; 2023. https://psnet.ahrq.gov/issue/cybersecurity-clinician The vulnerability of healthcare information technologies and devices to malicious interruptions is increasingly recognized as a patient safety hazard. This eight-e…

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