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1601. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
      March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…

1602. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49766/psn-pdf
      August 21, 2016 - Getting the (Right) Doctor, Right Away August 21, 2016 Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away The Case A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery. Postop…

1603. 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…

1604. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
      February 26, 2025 - spearheaded by the Learning Health Community that Charles Friedman from the University of Michigan leads

1605. Learning Health Systems for Patient Safety | PSNet
      psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
      February 26, 2025 - spearheaded by the Learning Health Community that Charles Friedman from the University of Michigan leads

1606. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45705/psn-pdf
      January 23, 2017 - ASPEN Safe Practices for Enteral Nutrition Therapy. January 23, 2017 Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN J Parenter Enteral Nutr. 2017;41(1):15-103. doi:10.1177/0148607116673053. https://psnet.ahrq.gov/issue/aspen-safe-practices-enteral-nutrition-therap…

1607. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44794/psn-pdf
      May 21, 2019 - Medical Device Use Error: Root Cause Analysis. May 21, 2019 Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790. https://psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis Applying human factors engineering to examine mistakes associated with medical device use can lead …

1608. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34982/psn-pdf
      July 14, 2010 - Development of the ICU safety reporting system. July 14, 2010 Wu AW, Holzmueller CG, Lubomski LH, et al. J Patient Saf. 2005;1(1):23-32. https://psnet.ahrq.gov/issue/development-icu-safety-reporting-system This AHRQ-funded study describes the development of a Web-based, voluntary, and anonymous reporting system. T…

1609. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836969/psn-pdf
      April 20, 2022 - Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety. April 20, 2022 ISMP Medication Safety Alert! Acute care edition. April 7, 2022; 27(2):1-6. https://psnet.ahrq.gov/issue/criminalization-human-error-and-guilty-verdict-travesty-justice-threatens- patient-safety…

1610. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45122/psn-pdf
      October 08, 2016 - Transformational leadership in nursing and medication safety education: a discussion paper. October 8, 2016 Vaismoradi M, Griffiths P, Turunen H, et al. Transformational leadership in nursing and medication safety education: a discussion paper.  J Nurs Manag. 2016;24(7):970-980. doi:10.1111/jonm.12387. https://psn…

1611. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35340/psn-pdf
      July 10, 2008 - Posthospital medication discrepancies: prevalence and contributing factors. July 10, 2008 Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842-1847. https://psnet.ahrq.gov/issue/posthospital-medication-discrepancies-prev…

1612. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45234/psn-pdf
      November 18, 2016 - Recommended responsibilities for management of MR safety. November 18, 2016 Calamante F, Ittermann B, Kanal E, et al. Recommended responsibilities for management of MR safety. J Magn Reson Imaging. 2016;44(5):1067-1069. doi:10.1002/jmri.25282. https://psnet.ahrq.gov/issue/recommended-responsibilities-management-mr…

1613. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47241/psn-pdf
      October 10, 2018 - Impact of high-reliability education on adverse event reporting by registered nurses. October 10, 2018 McFarland DM, Doucette JN. Impact of High-Reliability Education on Adverse Event Reporting by Registered Nurses. J Nurs Care Qual. 2018;33(3):285-290. doi:10.1097/NCQ.0000000000000291. https://psnet.ahrq.gov/issu…

1614. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46006/psn-pdf
      May 03, 2017 - Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine. May 3, 2017 Rosen MA, Mueller BU, Milstone AM, et al. Creating a Pediatric Joint Council to Promote Patient Safety and Quality, Governance, and Accountability Across Johns Hopkins…

1615. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/845345/psn-pdf
      March 01, 2023 - The role of language barriers on efficacy of rapid response teams. March 1, 2023 Raff L, Moore C, Raff E. The role of language barriers on efficacy of rapid response teams. Hosp Pract (1995). 2023;51(1):29-34. doi:10.1080/21548331.2022.2150416. https://psnet.ahrq.gov/issue/role-language-barriers-efficacy-rapid-res…

1616. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837590/psn-pdf
      June 29, 2022 - Diagnostic challenges in primary care: identifying and avoiding cognitive bias. June 29, 2022 Rosen PD, Klenzak S, Baptista S. Diagnostic challenges in primary care: identifying and avoiding cognitive bias. J Fam Pract. 2022;71(3):124-132. doi:10.12788/jfp.0380. https://psnet.ahrq.gov/issue/diagnostic-challenges-p…

1617. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46753/psn-pdf
      January 30, 2018 - Leadership oversight for patient safety programs: an essential element. January 30, 2018 Moffatt-Bruce SD, Clark S, DiMaio M, et al. Leadership Oversight for Patient Safety Programs: An Essential Element. Ann Thorac Surg. 2017;105(2):351-356. doi:10.1016/j.athoracsur.2017.11.021. https://psnet.ahrq.gov/issue/leade…

1618. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/48175/psn-pdf
      August 07, 2019 - Strengthening the medical error "meme pool." August 7, 2019 Mazer BL, Nabhan C. Strengthening the Medical Error "Meme Pool". J Gen Intern Med. 2019;34(10):2264- 2267. doi:10.1007/s11606-019-05156-7. https://psnet.ahrq.gov/issue/strengthening-medical-error-meme-pool Published estimates on the number preventable med…

1619. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35510/psn-pdf
      February 19, 2010 - Simulation study of rested versus sleep-deprived anesthesiologists. February 19, 2010 Howard SK, Gaba DM, Smith B, et al. Simulation study of rested versus sleep-deprived anesthesiologists. Anesthesiology. 2003;98(6):1345-1355. doi:10.1097/00000542-200306000-00008. https://psnet.ahrq.gov/issue/simulation-study-res…

1620. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45799/psn-pdf
      May 09, 2017 - Assessing frequency and risk of weight entry errors in pediatrics. May 9, 2017 Hagedorn PA, Kirkendall E, Kouril M, et al. Assessing Frequency and Risk of Weight Entry Errors in Pediatrics. JAMA Pediatr. 2017;171(4):392-393. doi:10.1001/jamapediatrics.2016.3865. https://psnet.ahrq.gov/issue/assessing-frequency-and…