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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - Double Dosing, by the Rules
Citation Text:
Cohen H. Double Dosing, by the Rules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/33754/psn-pdf
September 01, 2013 - And in order for the
system to be made perfect, it might take an unreasonable expenditure of institutional
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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - Errors in Sepsis Management
May 1, 2015
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/errors-sepsis-management
Case Objectives
Define sepsis, severe sepsis, and septic shock.
Describe the severe sepsis/septic shock resuscitation bundle.
Recognize commonly encou…
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psnet.ahrq.gov/node/49591/psn-pdf
October 01, 2009 - difficult-encounters-cmo-and-cno-respond
Case Objectives
Appreciate the risk of disruptive behavior and understand institutional
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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - Additionally, institutional leaders should consider using electronic triggers ( 10,11 ) and developing
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psnet.ahrq.gov/issue/first-do-no-harm-1
May 03, 2023 - Newsletter/Journal
FIRST Do No Harm.
Citation Text:
FIRST Do No Harm. Wakefield, MA: Quality and Patient Safety Division, Massachusetts Board of Registration in Medicine.
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psnet.ahrq.gov/issue/patient-safety-learning
January 12, 2022 - Multi-use Website
Patient Safety Learning.
Citation Text:
Patient Safety Learning. Patient Safety Learning.
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psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - Spotlight
Spotlight
An Inadvertent Bolus of Norepinephrine
Source and Credits
• This presentation is based on the May 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarina Fazio, PhD, RN, Emma Blackmon, PhD,
RN, Amy Doroy, PhD,…
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psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
February 01, 2010 - So you will continue to see an evolution in how we approach the institutional dimension of ACGME accreditation
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psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
February 01, 2010 - So you will continue to see an evolution in how we approach the institutional dimension of ACGME accreditation
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - Wrong-Time Error With High-Alert Medication
September 1, 2016
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
The Case
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
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psnet.ahrq.gov/node/33621/psn-pdf
November 01, 2005 - Rapid Response Teams: Lessons from the Early
Experience
November 1, 2005
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
Perspective
Health care organizations throughout the world have ide…
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psnet.ahrq.gov/node/49487/psn-pdf
August 21, 2005 - Surprise Wire
August 21, 2005
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/surprise-wire
The Case
A 39-year-old man with a history of liver disease presented to the emergency department (ED) with
gastrointestinal bleeding and altered mental status. Due to his clinic…
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psnet.ahrq.gov/node/33874/psn-pdf
February 01, 2019 - Building Systems Citizenship in Health Professions
Education: The Continued Call for Health Systems
Science Curricula
February 1, 2019
Gonzalo JD, Singh MK. Building Systems Citizenship in Health Professions Education: The Continued Call
for Health Systems Science Curricula. PSNet [internet]. 2019.
https://psnet.…
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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - This ensures that provider, and often even institutional, identities are shielded.
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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - Eptifibatide Epilogue
April 1, 2009
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue
The Case
A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute
coronary syndrome. Serial testing for mark…
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psnet.ahrq.gov/web-mm/its-all-syringe
February 01, 2013 - It's All in the Syringe
Citation Text:
Weingart SN. It's All in the Syringe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/49553/psn-pdf
January 01, 2008 - Contaminated or Not? Guidelines for Interpretation of
Positive Blood Cultures
January 1, 2008
Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
The…