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Showing results for "initiatives".

  1. 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…

  2. Spotlight Case July 2008 (ppt file)

    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…

  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. PowerPoint Presentation (ppt file)

    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…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33595/psn-pdf
    December 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety December 15, 2024 Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that th…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33725/psn-pdf
    February 01, 2012 - Balancing Supervision and Autonomy: An Ongoing Tension February 1, 2012 Dine JC, Myers JS. Balancing Supervision and Autonomy: An Ongoing Tension. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension Perspective Graduate Medical Education (GME) has changed …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33585/psn-pdf
    March 15, 2025 - Radiation Safety March 15, 2025 Radiation Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/radiation-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in 2025…

  8. Never Events | PSNet

    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…

  9. Duty Hours and Patient Safety | PSNet

    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…

  10. Responding to Patient Safety Events | PSNet

    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…

  11. The Deadly Duo | PSNet

    psnet.ahrq.gov/web-mm/deadly-duo
    April 28, 2021 - The Deadly Duo Citation Text: Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  12. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. | PSNet

    psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
    August 14, 2024 - SPOTLIGHT CASE Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. Citation Text: Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…

  13. What Was in Those Platelets? | PSNet

    psnet.ahrq.gov/web-mm/what-was-those-platelets
    August 28, 2024 - What Was in Those Platelets? Citation Text: Yomtovian R. What Was in Those Platelets? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  14. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet

    psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
    March 15, 2023 - SPOTLIGHT CASE Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Citation Text: Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…

  15. Dying in the Hospital With Advanced Dementia | PSNet

    psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
    November 01, 2016 - SPOTLIGHT CASE Dying in the Hospital With Advanced Dementia Citation Text: Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Ci…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838197/psn-pdf
    September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. September 28, 2022 Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022. https://psnet.…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49483/psn-pdf
    June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49768/psn-pdf
    September 01, 2016 - A Pill Organizing Plight September 1, 2016 McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/pill-organizing-plight Case Objectives Identify patients at high risk for adverse drug events. List drugs that are considered inappropriate in older patients. …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49566/psn-pdf
    July 01, 2008 - What Was in Those Platelets? July 1, 2008 Yomtovian R. What Was in Those Platelets? . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/what-was-those-platelets The Case A 47-year-old woman was admitted to the hospital for complex spinal surgery. The surgery went well without complications, and postoperativel…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49564/psn-pdf
    July 01, 2008 - Dependence vs. Pain July 1, 2008 Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dependence-vs-pain Case Objectives Define opioid dependence and opioid withdrawal syndrome. Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid Withdra…
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