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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - She only vaguely remembered the
necessary steps from the online computer module she had completed 5
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psnet.ahrq.gov/issue/free-lessons-aviation-safety
October 19, 2022 - Commentary
"Free lessons" in aviation safety.
Citation Text:
Rose A. “Free lessons” in aviation safety. Aircraft Engineering and Aerospace Technology. 2006;76(5). doi:10.1108/00022660410555130.
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psnet.ahrq.gov/issue/safety-relevant-mode-confusions-modelling-and-reducing-them
April 28, 2021 - Commentary
Safety-relevant mode confusions—modelling and reducing them.
Citation Text:
Bredereke J, Lankenau A. Safety-relevant mode confusions—modelling and reducing them. Reliab Eng Syst Saf. 2004;88(3). doi:10.1016/j.ress.2004.07.020.
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psnet.ahrq.gov/issue/safety-information-alaris-se-infusion-pumps
June 07, 2006 - Audiovisual
Safety Information on Alaris SE Infusion Pumps.
Citation Text:
Food and Drug Administration. 2006.
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November 15, 2…
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psnet.ahrq.gov/node/49794/psn-pdf
May 01, 2017 - Communication Error in a Closed ICU
May 1, 2017
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/communication-error-closed-icu
The Case
A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney
transplant), co…
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psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
July 23, 2024 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
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May 31, 2023
Innovation
Contact
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psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
April 24, 2024 - The Danger of 10% Intravenous Calcium Chloride Extravasation.
Citation Text:
The Danger of 10% Intravenous Calcium Chloride Extravasation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride
Extravasation.
April 26, 2023
The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
The Case
A 52-year-old man with a history of lymphoplasmacytic lymph…
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psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - Resources From the Same Author(s)
Comparative effectiveness of a serious game and an e-module
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psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
September 01, 2004 - She only vaguely remembered the necessary steps from the online computer module she had completed 5 weeks
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
April 10, 2024 - Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes
Citation Text:
Bakerjian D. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health…
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psnet.ahrq.gov/issue/use-cellular-telephones-hospital-environment
November 26, 2014 - Study
Use of cellular telephones in the hospital environment.
Citation Text:
Tri JL, Severson RP, Hyberger LK, et al. Use of cellular telephones in the hospital environment. Mayo Clin Proc. 2007;82(3):282-5.
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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
In Conversation with…Jennifer Daley, MD. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
Editor's note: Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the
organization for …
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psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - Reducing Preventable Patient Harm Due to Retained
Surgical Items: The RSI Bundle
May 29, 2024
https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
Summary
Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common
catego…
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Communication Error in a Closed ICU
Citation Text:
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49816/psn-pdf
January 01, 2018 - A Painful Medication Reconciliation Mishap
January 1, 2018
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
Case Objectives
Recognize that substance use disorders are common in patients with acute pain.
Understand th…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - National Healthcare Safety Network Biovigilance Component Hemovigilance Module Surveillance Protocol.
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psnet.ahrq.gov/periodic-issue/periodic-issue-290
May 26, 2021 - May 5, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, an…
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psnet.ahrq.gov/periodic-issue/periodic-issue-334
March 31, 2022 - March 23, 2022 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - Annual Perspective
Patient Safety in the Ambulatory Care Setting
August 5, 2022
View more articles from the same authors.
Citation Text:
Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. Rockville (MD): …