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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867845/psn-pdf
    February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary February 26, 2025 https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation- summary Summary This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843736/psn-pdf
    February 01, 2023 - Saved by ECMO February 1, 2023 Weiss NA. Saved by ECMO . PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/saved-ecmo The Case A 27-year-old pregnant woman was admitted at an estimated gestational age (EGA) of 29 weeks for increased shortness of breath. She was diagnosed with severe pulmonary arterial hyperte…

  3. 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…

  4. 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…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33602/psn-pdf
    March 15, 2025 - Individual Clinician Performance Issues March 15, 2025 Individual Clinician Performance Issues. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/individual-clinician-performance-issues PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current res…

  6. Computerized Provider Order Entry and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
    January 01, 2014 - Annual Perspective Computerized Provider Order Entry and Patient Safety Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015  View more articles from the same authors. Citation Text: Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…

  7. Topics | PSNet

    psnet.ahrq.gov/topics-0
    March 03, 2025 - Topics Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Featured Topics in Patient Safety Updated Date: March 3, 2025 …

  8. Accountability in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/accountability-patient-safety
    January 01, 2018 - Annual Perspective Accountability in Patient Safety Christopher Moriates, MD, and Robert M. Wachter, MD | January 1, 2015  View more articles from the same authors. Citation Text: Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. Rock…

  9. Patient Engagement in Safety | PSNet

    psnet.ahrq.gov/perspective/patient-engagement-safety
    January 01, 2018 - Annual Perspective Patient Engagement in Safety Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2017  View more articles from the same authors. Citation Text: Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. Rockville (MD): Agency…

  10. Transition Coaches® Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs | PSNet

    psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
    March 27, 2024 - Transition Coaches® Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 12, 2020 Innovation Contact …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60328/psn-pdf
    May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression May 27, 2020 Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory- …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848124/psn-pdf
    April 26, 2023 - In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring April 26, 2023 In Conversation with.. Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-ab…

  13. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions | PSNet

    psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
    November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions Lindsay E. Nicolle, MD | November 1, 2008  Also Read a Conversation View more articles from the same authors. Citation Text: Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Pr…

  14. In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE | PSNet

    psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
    August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE August 31, 2020  Also Read the Essay Citation Text: In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020.In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60858/psn-pdf
    August 26, 2020 - When the Meds Don’t Reach the Bed August 26, 2020 Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed The Case A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of chronic obs…

  16. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

  17. Life-Threatening Infant Overdose of Sodium Chloride | PSNet

    psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
    December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride Citation Text: Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Form…

  18. A Tale of Two Falls | PSNet

    psnet.ahrq.gov/web-mm/tale-two-falls
    March 27, 2024 - A Tale of Two Falls Citation Text: Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…

  19. The Impact of Communication on Medication Errors | PSNet

    psnet.ahrq.gov/web-mm/impact-communication-medication-errors
    August 01, 2009 - The Impact of Communication on Medication Errors Citation Text: Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: …

  20. Retained Surgical Items: Causation and Prevention | PSNet

    psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
    January 04, 2024 - Retained Surgical Items: Causation and Prevention Citation Text: Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX End…
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