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4901. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73953/psn-pdf
      October 27, 2021 - Deprescribing as a Patient Safety Strategy October 27, 2021 Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy Background Polypharmacy is defined as the act of taking five or more medications on a regular basis…

4902. Miscalculated Risk | PSNet
      psnet.ahrq.gov/web-mm/miscalculated-risk
      March 01, 2015 - Miscalculated Risk Citation Text: Strassels SA. Miscalculated Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

4903. Patient Advocacy in Patient Safety: Have Things Changed? | PSNet
      psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
      June 01, 2014 - co-chair of the Society for Participatory Medicine, Dave deBronkart, also known as e-Patient Dave, is a leading

4904. In Conversation With… Dave deBronkart | PSNet
      psnet.ahrq.gov/perspective/conversation-dave-debronkart
      June 01, 2014 - co-chair of the Society for Participatory Medicine, Dave deBronkart, also known as e-Patient Dave, is a leading

4905. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/848108/psn-pdf
      April 26, 2023 - Capnography can detect hypoventilation caused by decreased respiratory drive leading to a rise in end-tidal

4906. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847934/psn-pdf
      April 26, 2023 - Patient Safety Indicators April 26, 2023 Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/patient-safety-indicators Background Over the past 25 years, policymakers and providers, payers, and purchasers of health care have increasingly focused attention on pati…

4907. Thin Air | PSNet
      psnet.ahrq.gov/web-mm/thin-air
      March 01, 2006 - SPOTLIGHT CASE Thin Air Citation Text: Gaba DM. Thin Air. 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 …

4908. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850675/psn-pdf
      June 14, 2023 - Patient and Family Roles in Safety June 14, 2023 Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety Moving From Engagement to Partnership Involving patients and families in healthcare decisions about patient c…

4909. Discharged with IV antibiotics: When issues arise, who manages the complications? | PSNet
      psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
      October 10, 2017 - SPOTLIGHT CASE Discharged with IV antibiotics: When issues arise, who manages the complications? Citation Text: Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…

4910. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/860050/psn-pdf
      January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. January 4, 2024 Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant The Case A 2-month-old full-term male infant was b…

4911. The Hidden Danger of Unseen Intravenous Catheters | PSNet
      psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
      October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters Citation Text: Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google S…

4912. Medication Mix-Up: From Bad to Worse | PSNet
      psnet.ahrq.gov/web-mm/medication-mix-bad-worse
      March 01, 2018 - Medication Mix-Up: From Bad to Worse Citation Text: Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote …

4913. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73455/psn-pdf
      June 30, 2021 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks June 30, 2021 Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks The Case At the…

4914. How Do Providers Recover From Errors? | PSNet
      psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
      May 22, 2024 - SPOTLIGHT CASE How Do Providers Recover From Errors? Citation Text: West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar Bi…

4915. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73434/psn-pdf
      June 30, 2021 - The Consequences of Miscommunication Regarding a Possible Artifact June 30, 2021 Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact Disclosure of Relevant Financial Relationships…

4916. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50928/psn-pdf
      February 21, 2020 - Updates in the Role of Health IT in Patient Safety February 21, 2020 Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety Background Health information technology (HIT) has the potential…

4917. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49600/psn-pdf
      April 01, 2010 - Bad Writing, Wrong Medication April 1, 2010 Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication Case Objectives Differentiate between a medication error and an adverse drug event. Appreciate the system complexities involved in medication erro…

4918. Clostridium Difficile Relapse Secondary to Medication Access Issue | PSNet
      psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
      October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue Citation Text: Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Cit…

4919. Continuity Errors in Resident Clinic | PSNet
      psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
      October 02, 2019 - Continuity Errors in Resident Clinic Citation Text: Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

4920. Tacit Handover, Overt Mishap | PSNet
      psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
      August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…