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4421. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33574/psn-pdf
      March 15, 2025 - Ambulatory Care Safety March 15, 2025 Ambulatory Care Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/ambulatory-care-safety 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 safety field. Las…

4422. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33669/psn-pdf
      May 01, 2018 - Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? May 1, 2018 Peterson JF. Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-system…

4423. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33571/psn-pdf
      March 15, 2025 - Reporting Patient Safety Events March 15, 2025 Reporting Patient Safety Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/reporting-patient-safety-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in th…

4424. Handoffs | PSNet
      psnet.ahrq.gov/primer/handoffs
      October 18, 2023 - Handoffs Citation Text: Handoffs and Signouts. 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…

4425. Culture of Safety | PSNet
      psnet.ahrq.gov/primer/culture-safety
      September 15, 2024 - Culture of Safety Citation Text: Culture of 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 Dow…

4426. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837958/psn-pdf
      December 01, 2021 - EMS Perils from Hospital Overcrowding August 31, 2022 Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding The Case A 71-year-old man with a history of postoperative septic knee arthritis (status: post-intravenous…

4427. Getting Into Patient Safety: A Personal Story | PSNet
      psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
      August 01, 2006 - Getting Into Patient Safety: A Personal Story Jeffrey B. Cooper, PhD | August 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. Rockville (MD): A…

4428. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/851869/psn-pdf
      July 31, 2023 - Building Capacity for Patient Safety July 31, 2023 Hoffman R, Mossburg S, Van CM. Building Capacity for Patient Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/building-capacity-patient-safety In its 2019 report, Safer Together: A National Action Plan to Advance Patient Safety, the National Steer…

4429. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.227_slideshow.ppt
      November 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Treatment Challenges After Discharge * * Source and Credits This presentation is based on the November 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Chase Coffey, MD, Henry Ford Health System,…

4430. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33612/psn-pdf
      May 01, 2005 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience May 1, 2005 Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/organizat…

4431. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
      July 01, 2003 - PowerPoint Presentation Spotlight Case July 2003 Code Status Confusion webmm.ahrq.gov Source and Credits This presentation is based on the July 2003 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Bernard Lo, MD, Univers…

4432. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.242_slideshow.ppt
      June 01, 2011 - Spotlight Case July 2008 Spotlight Case The ECG is Not Normal * * Source and Credits This presentation is based on the June 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Abigail Zuger, MD, Columbia University Editor, AHRQ WebM&M: Robe…

4433. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
      April 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Bad Writing, Wrong Medication * * Source and Credits This presentation is based on the April 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Beth Devine, PharmD, MBA, PhD University of Washingto…

4434. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49652/psn-pdf
      May 01, 2012 - Double Dose at Transfer May 1, 2012 Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/double-dose-transfer The Case A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythe…

4435. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49496/psn-pdf
      December 01, 2005 - Discharged Blindly December 1, 2005 Iezzoni LI. Discharged Blindly. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/discharged-blindly The Case An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to receive enoxaparin (Lovenox) for self-administration at home…

4436. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
      February 01, 2018 - PowerPoint Presentation Spotlight Signout Fallout 1 Source and Credits This presentation is based on the February 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…

4437. Pharmacist's Role in Medication Safety | PSNet
      psnet.ahrq.gov/primer/pharmacists-role-medication-safety
      March 14, 2018 - Pharmacist's Role in Medication Safety Citation Text: The Pharmacist's Role in Medication 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…

4438. Readmissions and Adverse Events After Discharge | PSNet
      psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
      April 27, 2022 - Readmissions and Adverse Events After Discharge Citation Text: Readmissions and Adverse Events After Discharge. 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…

4439. Ambulatory Care Safety | PSNet
      psnet.ahrq.gov/primer/ambulatory-care-safety
      December 15, 2024 - Ambulatory Care Safety Citation Text: Ambulatory Care 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 …

4440. Adverse Events, Near Misses, and Errors | PSNet
      psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
      March 30, 2022 - Adverse Events, Near Misses, and Errors Citation Text: Adverse Events, Near Misses, and Errors. 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 X…