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3121. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49866/psn-pdf
      June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the Operating Room June 1, 2019 Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room The Case A 43-year-old woman was admi…

3122. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33824/psn-pdf
      January 01, 2016 - Patient Safety and Opioid Medications January 1, 2016 Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications Annual Perspective 2016 Opioid medications confer significant risks of harm, including overdose death …

3123. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33679/psn-pdf
      January 01, 2009 - Disclosure of Medical Error January 1, 2009 Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/disclosure-medical-error Perspective Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater discl…

3124. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33812/psn-pdf
      August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD August 1, 2016 In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd Editor's note: Dr. Perea-Pérez is Director de la Escuela de Medicina Legal y For…

3125. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49548/psn-pdf
      October 01, 2007 - Toxic Tachycardia October 1, 2007 Wartofsky L. Toxic Tachycardia. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/toxic-tachycardia The Case A 66-year-old woman with a past medical history of hypertension and breast cancer was admitted with abdominal pain. She complained of 3 weeks of progressive severe rig…

3126. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60169/psn-pdf
      March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room. March 25, 2020 Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…

3127. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49435/psn-pdf
      February 01, 2004 - X-ray Flip February 1, 2004 Shapiro MJ. X-ray Flip. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/x-ray-flip The Case A 19-year-old man presented to the emergency department with respiratory distress after blunt chest trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…

3128. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
      February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…

3129. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49634/psn-pdf
      September 01, 2011 - Situational (Un)Awareness September 1, 2011 Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/situational-unawareness The Case A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver function tests, including a bi…

3130. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866395/psn-pdf
      July 23, 2024 - Rescue Improvement Conference Innovation Summary July 23, 2024 https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary Summary The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure to rescue with a particular focus on communication and com…

3131. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866841/psn-pdf
      September 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary September 23, 2024 https://psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and- intervention-innovation Summary UNC Health is a nonprofit healthcare system of more than 500 clinics and…

3132. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50393/psn-pdf
      September 01, 2019 - Patient Safety and the Evolution of WebM&M and PSNet September 1, 2019 Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet Perspective Progress in any field requires scholarship and dissem…

3133. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49697/psn-pdf
      December 01, 2013 - Check the Anesthesia Machine December 1, 2013 Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/check-anesthesia-machine The Case A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension, diabetes, sleep apnea…

3134. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33761/psn-pdf
      February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness February 1, 2014 Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…

3135. Strategies and Approaches for Investigating Patient Safety Events | PSNet
      psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
      March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events Citation Text: Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…

3136. Missed Nursing Care | PSNet
      psnet.ahrq.gov/primer/missed-nursing-care
      September 15, 2024 - Missed Nursing Care Citation Text: Missed Nursing Care. 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 …

3137. Opioid Safety | PSNet
      psnet.ahrq.gov/primer/opioid-safety
      December 15, 2024 - Opioid Safety Citation Text: Opioid Safety. 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 Download Ci…

3138. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49768/psn-pdf
      September 01, 2016 - Evidence demonstrates that pharmacist involvement leads to reductions in ADEs and readmissions of 30%

3139. Spotlight
      psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
      January 01, 2025 - This common cognitive bias leads to premature closure, or the acceptance of a diagnosis before it is

3140. A Pill Organizing Plight | PSNet
      psnet.ahrq.gov/web-mm/pill-organizing-plight
      June 19, 2018 - Evidence demonstrates that pharmacist involvement leads to reductions in ADEs and readmissions of 30%