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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. 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…
  8. 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 …
  9. 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,…
  10. Psn-Pdf (pdf file)

    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 …
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. 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…
  15. Psn-Pdf (pdf file)

    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…
  16. 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…
  17. 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…
  18. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…
  19. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
  20. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

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