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  1. psnet.ahrq.gov/issue/contributions-tele-intensive-care-unit-tele-icu-technology-quality-care-and-patient-safety
    February 16, 2022 - Study Contributions of tele-intensive care unit (tele-ICU) technology to quality of care and patient safety. Citation Text: Khunlertkit A, Carayon P. Contributions of tele-intensive care unit (Tele-ICU) technology to quality of care and patient safety. J Crit Care. 2013;28(3):315.e1-12…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49866/psn-pdf
    June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the Operating Room June 1, 2019 Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room The Case A 43-year-old woman was admi…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33824/psn-pdf
    January 01, 2016 - Patient Safety and Opioid Medications January 1, 2016 Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications Annual Perspective 2016 Opioid medications confer significant risks of harm, including overdose death …
  4. psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
    January 01, 2014 - Annual Perspective Computerized Provider Order Entry and Patient Safety Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015  View more articles from the same authors. Citation Text: Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33761/psn-pdf
    February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness February 1, 2014 Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…
  6. psnet.ahrq.gov/web-mm/lap-burn
    March 01, 2018 - Lap Burn Citation Text: Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867845/psn-pdf
    February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary February 26, 2025 https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation- summary Summary This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
  8. psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
    March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008  View more articles from the same authors. Citation Text: Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33631/psn-pdf
    April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety April 1, 2006 Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49634/psn-pdf
    September 01, 2011 - Situational (Un)Awareness September 1, 2011 Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/situational-unawareness The Case A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver function tests, including a bi…
  11. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
    August 01, 2015 - PowerPoint Presentation Spotlight Privacy or Safety? 1 This presentation is based on the July/August 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John D. Halamka, MD, MS, Beth Israel Deaconess Medical Center; and Deven McGraw, JD, MPH, LLM…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49839/psn-pdf
    August 01, 2018 - Mixup Beyond the Medication Label August 1, 2018 Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label The Case An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another hospi…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49503/psn-pdf
    February 01, 2006 - Workaround Error February 1, 2006 Pape T. Workaround Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/workaround-error The Case A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospita…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49520/psn-pdf
    September 01, 2006 - DNR in the OR and Afterwards September 1, 2006 Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards The Case An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and suffered a fractured femur. After initial eval…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49409/psn-pdf
    July 01, 2003 - Feeling No Pain July 1, 2003 Bogner MS. Feeling No Pain. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/feeling-no-pain The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49435/psn-pdf
    February 01, 2004 - X-ray Flip February 1, 2004 Shapiro MJ. X-ray Flip. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/x-ray-flip The Case A 19-year-old man presented to the emergency department with respiratory distress after blunt chest trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49841/psn-pdf
    September 01, 2018 - Chemotherapy Administration Safety Standards September 1, 2018 Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards The Case A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33850/psn-pdf
    January 01, 2018 - EHR Copy and Paste and Patient Safety January 1, 2018 Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety Perspective Although the ability to copy and paste text is a central benefit of computing in general, and electronic…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49469/psn-pdf
    December 01, 2004 - Overriding Considerations December 1, 2004 Holtzman NA. Overriding Considerations. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/overriding-considerations The Case Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic testing for a variety of condition…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49590/psn-pdf
    January 01, 2010 - Is the Admission Drug Dose Too Low? August 1, 2009 Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low The Case A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to the hospit…

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