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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33713/psn-pdf
    June 01, 2011 - The Safety of Medical Devices June 1, 2011 Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/safety-medical-devices Perspective Edward Tenner is right. Technology does have reverberations, including unintended consequences, or "revenge effects."(1) While such dra…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49524/psn-pdf
    November 01, 2006 - Secured But Not Always Safe November 1, 2006 Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/secured-not-always-safe The Case An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative osteoarthritis. She received spinal …
  3. 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…
  4. psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
    December 15, 2024 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events Citation Text: Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cit…
  5. psnet.ahrq.gov/perspective/update-patient-engagement-safety
    January 01, 2017 - Annual Perspective Update: Patient Engagement in Safety Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2018  View more articles from the same authors. Citation Text: Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. Rockvi…
  6. psnet.ahrq.gov/primer/human-factors-engineering
    December 15, 2024 - Human Factors Engineering Citation Text: Human Factors Engineering. 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 R…
  7. psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
    December 01, 2005 - Introducing the Redesigned AHRQ Patient Safety Network Robert M. Wachter, MD | November 1, 2015  View more articles from the same authors. Citation Text: Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. Rockville (MD): Agency f…
  8. psnet.ahrq.gov/primer/surgical-site-infections
    December 15, 2024 - Surgical Site Infections Citation Text: Surgical Site Infections. 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…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33872/psn-pdf
    January 01, 2018 - Update: Patient Engagement in Safety January 1, 2018 Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/update-patient-engagement-safety Annual Perspective 2018 Background Patient engagement has become a cornerstone of patient safety. A Patient Saf…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49658/psn-pdf
    July 01, 2012 - Misleading Complaint July 1, 2012 Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/misleading-complaint The Case A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with complaints of knee problems. The triage nurse docu…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72516/psn-pdf
    November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
  12. psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx Spotlight Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes Source and Credits • This presentation is based on the April 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/we…
  13. psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
    July 01, 2011 - SPOTLIGHT CASE Spotlight: Mistaken Attribution, Diagnostic Misstep Citation Text: Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citat…
  14. psnet.ahrq.gov/web-mm/mobility-lost-icu
    August 01, 2018 - SPOTLIGHT CASE Mobility Lost in the ICU Citation Text: Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851389/psn-pdf
    July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer Summary Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, a…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60268/psn-pdf
    April 29, 2020 - Complications of ECMO During Transport April 29, 2020 Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport The Case A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with acute on chro…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72517/psn-pdf
    November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. November 25, 2020 Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73102/psn-pdf
    July 01, 2022 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use March 31, 2021 https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail- community-dwelling Summary Care management staff (such …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73128/psn-pdf
    July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. April 7, 2021 https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications- and-enhances Summary The Hospital at Homesm program provides hospital-level care…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49849/psn-pdf
    January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep January 1, 2019 Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep Case Objectives List the patient safety events that are unique to in…

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