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  1. 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…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74242/psn-pdf
    January 07, 2022 - The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps January 7, 2022 Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps The Case A 52-year-old woman w…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33719/psn-pdf
    October 01, 2011 - The Context Is the Intervention October 1, 2011 Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/context-intervention Perspective Introduction What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this context.…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33633/psn-pdf
    May 01, 2006 - Patient Safety in the Physician Office Setting May 1, 2006 Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting Perspective Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …
  5. psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
    February 26, 2025 - The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January 5, 2021 Innovation Contact …
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.212_slideshow.ppt
    February 01, 2010 - Spotlight Case July 2008 Spotlight Case Adolescent Diabetes: A Routine Visit? Source and Credits This presentation is based on the February 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Gail B. Slap, MD, MSc, Children’s Hospital of P…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866846/psn-pdf
    September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 24, 2024 Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/zero…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33677/psn-pdf
    November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions November 1, 2008 Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions Perspective U…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33581/psn-pdf
    December 15, 2024 - Medication Errors and Adverse Drug Events December 15, 2024 Medication Errors and Adverse Drug Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect cu…
  10. psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
    June 01, 2014 - Mixup Beyond the Medication Label Citation Text: Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50843/psn-pdf
    January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia January 29, 2020 Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia The Case A 54-year-old man was brought t…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33701/psn-pdf
    October 01, 2010 - What Makes a Good Checklist October 1, 2010 McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/what-makes-good-checklist Perspective The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex tasks. Checklists have lo…
  13. psnet.ahrq.gov/web-mm/overriding-considerations
    March 09, 2009 - Overriding Considerations Citation Text: Holtzman NA. Overriding Considerations. 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 tagg…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840255/psn-pdf
    November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions November 16, 2022 Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions . PSNet [internet]. 2022. https://psnet.ahrq.gov/perspecti…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49756/psn-pdf
    April 01, 2016 - Lost in Sign Out and Documentation April 1, 2016 Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation The Case A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the emergency physician, …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853772/psn-pdf
    September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable September 27, 2023 Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable The Case A fourteen-ye…
  17. psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
    December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles Citation Text: Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citatio…
  18. psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
    September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR Citation Text: Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49785/psn-pdf
    February 01, 2017 - Refused Medication Error February 1, 2017 Foley M. Refused Medication Error. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/refused-medication-error The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was alert to self and place only. The patient h…
  20. psnet.ahrq.gov/primers-0
    March 15, 2025 - Primers Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Latest Primers New Clinical Decision Support Systems …

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