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  1. Spotlight Case September 2006 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
    September 01, 2006 - Spotlight Case September 2006 Spotlight Case September 2006 Triple Handoff Source and Credits This presentation is based on the September 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Arpana Vidyarthi, MD, UCSF Sc…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49586/psn-pdf
    May 01, 2009 - Vial Mistakes Involving Heparin May 1, 2009 Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin The Case A 65-year-old man was admitted to the hospital for an elective left carotid endarterectomy. During the procedure, the surgeon re…

  3. In Conversation With… Michelle Mello, MPhil, JD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
    July 01, 2017 - That leads to the reality that most instances of negligent injury never are addressed in the legal system

  4. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? | PSNet

    psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-disciplinary-actions-and-complaints-what-do-we-know
    July 01, 2017 - That leads to the reality that most instances of negligent injury never are addressed in the legal system

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33578/psn-pdf
    September 15, 2024 - Human Factors Engineering September 15, 2024 Human Factors Engineering. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/human-factors-engineering PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safe…

  6. Swiss Cheese Model | PSNet

    psnet.ahrq.gov/glossary/swiss-cheese-model
    September 13, 2021 - Swiss Cheese Model September 13, 2021 Anonymous (not verified) Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safe…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45222/psn-pdf
    June 08, 2016 - A program to prevent catheter-associated urinary tract infection in acute care. June 8, 2016 Saint S, Greene T, Krein SL, et al. A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care. New Engl J Med. 2016;374(22):2111-2119. doi:10.1056/NEJMoa1504906. https://psnet.ahrq.gov/issue/program-pr…

  8. Tennessee Center for Patient Safety. | PSNet

    psnet.ahrq.gov/issue/tennessee-center-patient-safety
    May 03, 2023 - Multi-use Website Tennessee Center for Patient Safety. Citation Text: Tennessee Center for Patient Safety. Tennessee Center for Patient Safety. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

  9. Connecticut Center for Patient Safety. | PSNet

    psnet.ahrq.gov/issue/connecticut-center-patient-safety
    May 03, 2023 - Multi-use Website Connecticut Center for Patient Safety. Citation Text: Connecticut Center for Patient Safety. Connecticut Center for Patient Safety Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

  10. ACOG Committee Statement No. 10: Racial and Ethnic Inequities in Obstetrics and Gynecology. | PSNet

    psnet.ahrq.gov/issue/acog-committee-statement-no-10-racial-and-ethnic-inequities-obstetrics-and-gynecology
    November 13, 2024 - Organizational Policy/Guidelines ACOG Committee Statement No. 10: Racial and Ethnic Inequities in Obstetrics and Gynecology. Citation Text: ACOG Committee Statement No. 10: Racial and Ethnic Inequities in Obstetrics and Gynecology. Obstet Gynecol. 2024;144(3):e62-e74. doi:10.1097/aog.000…

  11. Data docs. | PSNet

    psnet.ahrq.gov/issue/data-docs
    March 02, 2016 - Newspaper/Magazine Article Data docs. Citation Text: Data docs. Wherry R. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL November 4, 2015 Wherry R. …

  12. Risk factors associated with incorrect surgical counts. | PSNet

    psnet.ahrq.gov/issue/risk-factors-associated-incorrect-surgical-counts
    October 20, 2010 - Study Risk factors associated with incorrect surgical counts. Citation Text: Rowlands A. Risk factors associated with incorrect surgical counts. AORN J. 2012;96(3):272-84. doi:10.1016/j.aorn.2012.06.012. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XM…

  13. Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging. | PSNet

    psnet.ahrq.gov/issue/practice-advisory-anesthetic-care-magnetic-resonance-imaging-report-american-society
    August 09, 2023 - Commentary Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging. Citation Text: Practice advisory on anesthetic care for magnetic resonance imaging: an updat…

  14. U.S. inaction lets look-alike tubes kill patients. | PSNet

    psnet.ahrq.gov/issue/us-inaction-lets-look-alike-tubes-kill-patients
    September 01, 2008 - Newspaper/Magazine Article U.S. inaction lets look-alike tubes kill patients. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL September 1, 2010 View more articles from the same aut…

  15. A Room Without Orders | PSNet

    psnet.ahrq.gov/web-mm/room-without-orders
    September 01, 2011 - Cases Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads

  16. Ensuring Patient and Workforce Safety Culture in Healthcare | PSNet

    psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
    March 27, 2024 - burnout rate has a compounding effect: It negatively affects individual HCWs and it also potentially leads

  17. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! | PSNet

    psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
    February 01, 2023 - With the decrease in plasma glucose levels, insulin secretion by the pancreas is reduced, which then leads

  18. Duplicate Insulin Order | PSNet

    psnet.ahrq.gov/web-mm/duplicate-insulin-order
    May 04, 2012 - August 5, 2022 WebM&M Cases Lapse in Antibiotics Leads

  19. Who Nose Where the Airway Is? | PSNet

    psnet.ahrq.gov/web-mm/who-nose-where-airway
    May 01, 2016 - February 1, 2006 WebM&M Cases A Costly Colonoscopy Leads

  20. How Do Providers Recover From Errors? | PSNet

    psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
    May 22, 2024 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads
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