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9881. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49398/psn-pdf
      May 01, 2003 - Bloody BP Cuff May 1, 2003 Madan AK. Bloody BP Cuff. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/bloody-bp-cuff The Case Patient #1, a 28-year-old male, was a trauma patient following a motor vehicle collision into a cement pillar. Patient #1 was in the trauma bay with massive injuries and profuse bleed…

9882. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60652/psn-pdf
      June 29, 2020 - In Conversation With... Anna Legreid Dopp, Pharm. D June 29, 2020 In Conversation With.. Anna Legreid Dopp, Pharm. D. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d Editor’s note: Anna Legreid Dopp, Pharm. D is the Senior Director of Clinical Guidelines and Quality…

9883. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49433/psn-pdf
      June 23, 2021 - Environmental Safety in the OR February 1, 2004 Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/environmental-safety-or The Case The infection control department of a hospital noticed a marked increase in the rates of post-operative sternal wound inf…

9884. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49662/psn-pdf
      August 01, 2012 - Wrong Turn through Colon: Misplaced PEG August 1, 2012 Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg The Case An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…

9885. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866848/psn-pdf
      September 25, 2024 - In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 25, 2024 Thomas E, Mossburg S, Lee M. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. …

9886. Observational Audits (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/nursing-home/materials/observational-audits.pdf
      March 01, 2021 - Observational Audits Observational Audits A Pathway to Improving Infection Prevention and Preventing the Spread of COVID-19 Infection prevention is the vital first line of defense against COVID-19. Observational audits are the best way to understand if your staff fully comply with infection prevention p…

9887. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40641/psn-pdf
      July 27, 2011 - Error in body weight estimation leads to inadequate parenteral anticoagulation. July 27, 2011 Macedo LG dos R, de Oliveira L, Pintão MC, et al. Error in body weight estimation leads to inadequate parenteral anticoagulation. Am J Emerg Med. 2011;29(6):613-7. doi:10.1016/j.ajem.2010.01.006. https://psnet.ahrq.gov/is…

9888. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38886/psn-pdf
      August 26, 2009 - Medication overdoses leading to emergency department visits among children. August 26, 2009 Schillie SF, Shehab N, Thomas KE, et al. Medication overdoses leading to emergency department visits among children. Am J Prev Med. 2009;37(3):181-7. doi:10.1016/j.amepre.2009.05.018. https://psnet.ahrq.gov/issue/medication…

9889. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46463/psn-pdf
      October 04, 2017 - Effectively leading for quality. October 4, 2017 Lachman P, Nicklin W. Effectively leading for quality. Healthc Manage Forum. 2017;30(5):233-236. doi:10.1177/0840470417706705. https://psnet.ahrq.gov/issue/effectively-leading-quality Hospital boards and executives can help drive safety improvement. This commentary …

9890. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41331/psn-pdf
      October 03, 2017 - Leading a highly visible hospital through a serious reportable event. October 3, 2017 Erickson JI. Leading a highly visible hospital through a serious reportable event. J Nurs Adm. 2012;42(3):131-3. doi:10.1097/NNA.0b013e31824808b6. https://psnet.ahrq.gov/issue/leading-highly-visible-hospital-through-serious-repor…

9891. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38619/psn-pdf
      May 07, 2018 - Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter. May 7, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2. https://psnet.ahrq.gov/issue/failed-check-system-chemotherapy-leads-pharmacists-no-contest-plea- involuntary-manslaughter …

9892. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37417/psn-pdf
      March 28, 2012 - Medication use leading to emergency department visits for adverse drug events in older adults. March 28, 2012 Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147(11):755-765. https://psnet.ahrq.gov/issue/med…

9893. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39110/psn-pdf
      June 10, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3. https://psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time- leading-dru…

9894. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46081/psn-pdf
      April 19, 2017 - Why are medical errors still a leading cause of death? April 19, 2017 Headley M. https://psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death This magazine article explores the need for robust research and effective reporting to better understand the prevalence of medical errors and how to prevent…

9895. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44239/psn-pdf
      September 29, 2017 - When medical care leads to harm—difficulty finding words: a teachable moment. September 29, 2017 Chamberlain E, DiVeronica M, Segura R. When medical care leads to harm- difficulty finding words: a teachable moment. JAMA Intern Med. 2015;175(8):1271-1272. doi:10.1001/jamainternmed.2015.2334. https://psnet.ahrq.gov/…

9896. Sources of NIS Data and State-Specific Restrictions 2005
      hcup-us.ahrq.gov/db/nation/nis/nis_2005_stspecific_restr.jsp
      January 01, 2005 - Sources of NIS Data and State-Specific Restrictions 2005 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs…

9897. Sources of NIS Data and State-Specific Restrictions 2004
      hcup-us.ahrq.gov/db/nation/nis/nis_2004_stspecific_restr.jsp
      January 01, 2004 - Sources of NIS Data and State-Specific Restrictions 2004 An official website of the Department of Health & Human Services Search All AHRQ Websites Careers Contact Us Espanol FAQs…

9898. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38598/psn-pdf
      June 03, 2010 - Leading successful rapid response teams: a multisite implementation evaluation. June 3, 2010 Donaldson N, Shapiro S, Scott M, et al. Leading successful rapid response teams: A multisite implementation evaluation. J Nurs Adm. 2009;39(4):176-81. doi:10.1097/NNA.0b013e31819c9ce9. https://psnet.ahrq.gov/issue/leading-…

9899. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43201/psn-pdf
      May 21, 2014 - New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings. May 21, 2014 Washington, DC: US Department of Health and Human Services; May 7, 2014. https://psnet.ahrq.gov/issue/new-hhs-data-shows-major-strides-made-patient-safety-leading-improved- care-and-savings Comparing safety…

9900. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45357/psn-pdf
      October 09, 2016 - Leading article: how can I optimise my role as a leader within the surgical team? October 9, 2016 Green B, Mitchell DA, Stevenson P, et al. Leading article: how can I optimise my role as a leader within the surgical team? Br J Oral Maxillofac Surg. 2016;54(8):847-850. doi:10.1016/j.bjoms.2016.05.035. https://psnet…