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psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - Improving Patient Safety and Team Communication
through Daily Huddles
January 29, 2020
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet].
2020.
https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
Background
Communicat…
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psnet.ahrq.gov/node/50699/psn-pdf
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
Background
Older patients are at a particular risk of experiencing a patient safety event. Stud…
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - Hemolysis Holdup
May 1, 2017
Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic
kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
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psnet.ahrq.gov/node/50610/psn-pdf
October 30, 2019 - First, Do No Harm: Value-driven Patient Safety in the
Neonatal Intensive Care Unit
October 30, 2019
Profit J, Scheid A, Ridout E. First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care
Unit. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safe…
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psnet.ahrq.gov/node/49460/psn-pdf
September 01, 2004 - Security Lapse
September 1, 2004
Mason D. Security Lapse. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/security-lapse
The Case
A medical student learned that the hospital's radiology image library was accessible throughout the
university's computer system, meaning that patient x-rays could be viewed in d…
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psnet.ahrq.gov/node/49541/psn-pdf
August 21, 2007 - Mark My Tooth
August 21, 2007
Smith RA. Mark My Tooth. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/mark-my-tooth
The Case
A 45-year-old healthy man was scheduled to have two teeth extracted for progressive dental caries. The
patient underwent the extractions, awoke from the anesthesia, and then realized…
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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…
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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 …
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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,…
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psnet.ahrq.gov/node/49743/psn-pdf
September 01, 2015 - Dual Therapy Debacle
September 1, 2015
Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/dual-therapy-debacle
The Case
An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction,
hyperlipidemia, obesity, and a long history of tobacco use …
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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/33627/psn-pdf
February 01, 2006 - Removing Insult from Injury—Disclosing Adverse Events
February 1, 2006
Wu AW. Removing Insult from Injury—Disclosing Adverse Events. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
Perspective
You pull into a parking space, swing open the car door, and ar…
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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - A Picture Speaks 1000 Words
September 1, 2013
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words
The Case
A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection
repair presented with chest p…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - Spotlight Case July 2008
Spotlight Case
Right Regimen, Wrong Cancer: Patient Catches Medical Error
*
*
Source and Credits
This presentation is based on the May 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph O. Jacobson, MD, MSc…
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psnet.ahrq.gov/node/33655/psn-pdf
August 01, 2007 - The PeaceHealth Governance Journey in Support of
Quality and Safety
August 1, 2007
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
Perspective
In recent years, the…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
June 01, 2014 - PowerPoint Presentation
Spotlight
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
1
This presentation is based on the June 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas A. Smith, CHPA, CPP, President, Healthc…
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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…
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psnet.ahrq.gov/primer/never-events
June 15, 2024 - Never Events
Citation Text:
Never Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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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/primer/responding-patient-safety-events
October 18, 2023 - Responding to Patient Safety Events
Citation Text:
Shaikh U. Responding to Patient Safety Events. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…