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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33647/psn-pdf
    March 01, 2007 - The Role of the Patient in Improving Patient Safety March 1, 2007 Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/role-patient-improving-patient-safety Perspective Patients have three roles in improving patient safety: helping to ensure thei…

  2. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? | PSNet

    psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
    June 24, 2020 - SPOTLIGHT CASE Fatal Error in Neonate: Does "Just Culture" Provide an Answer? Citation Text: Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …

  3. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy | PSNet

    psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
    July 01, 2008 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy Citation Text: Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49607/psn-pdf
    August 01, 2010 - Missed Patient Assignment: Is Anyone There? August 1, 2010 Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there The Case In one hospital, nurses' patient assignments were communicated by listing the…

  5. Safeguarding Diagnostic Testing at the Point of Care | PSNet

    psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
    September 30, 2011 - Safeguarding Diagnostic Testing at the Point of Care Citation Text: Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: …

  6. In Conversation with...Steven J. Spear, DBA, MS, MS | PSNet

    psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
    August 01, 2009 - Technology implementation and workarounds in the nursing home.

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36610/psn-pdf
    January 14, 2011 - Prevent medication errors: a New Year's resolution: teaching patients about their medications. January 14, 2011 Polzien G. Prevent medication errors: A New Year's resolution: teaching patients about their medications. Home Healthc Nurse. 2007;25(1):59-62. https://psnet.ahrq.gov/issue/prevent-medication-errors-new-…

  8. How-to Guide: Multidisciplinary Rounds. | PSNet

    psnet.ahrq.gov/issue/how-guide-multidisciplinary-rounds
    July 12, 2017 - Book/Report How-to Guide: Multidisciplinary Rounds. Citation Text: How-to Guide: Multidisciplinary Rounds. Cambridge, MA: Institute for Healthcare Improvement; February 2010. Copy Citation Save Save to your library Print Download PDF Share …

  9. Clear liquids may place patients at risk. | PSNet

    psnet.ahrq.gov/issue/clear-liquids-may-place-patients-risk
    May 19, 2021 - Newspaper/Magazine Article Clear liquids may place patients at risk. Citation Text: Clear liquids may place patients at risk. Pennsylvania Patient Safety Reporting System. Copy Citation Save Save to your library Print Download PDF Share F…

  10. Coronavirus strains hospitals, cancer patients face treatment delays, uncertainty. | PSNet

    psnet.ahrq.gov/issue/coronavirus-strains-hospitals-cancer-patients-face-treatment-delays-uncertainty
    April 27, 2016 - Newspaper/Magazine Article Coronavirus strains hospitals, cancer patients face treatment delays, uncertainty. Citation Text: Coronavirus strains hospitals, cancer patients face treatment delays, uncertainty. Stone W. Health Shots. National Public Radio. April 2, 2020. Copy Citation …

  11. Why accountability sharing in health care organizational cultures means patients are probably safer. | PSNet

    psnet.ahrq.gov/issue/why-accountability-sharing-health-care-organizational-cultures-means-patients-are-probably
    May 27, 2020 - Commentary Why accountability sharing in health care organizational cultures means patients are probably safer. Citation Text: Why accountability sharing in health care organizational cultures means patients are probably safer. Eng DM, Schweikart SJ. AMA J Ethics. 2020;22(9):e779-e783. …

  12. Hospital tones down alarms to reduce fatigue, enhance safety. | PSNet

    psnet.ahrq.gov/issue/hospital-tones-down-alarms-reduce-fatigue-enhance-safety
    June 08, 2011 - Newspaper/Magazine Article Hospital tones down alarms to reduce fatigue, enhance safety. Citation Text: Hospital tones down alarms to reduce fatigue, enhance safety. Olson J. Copy Citation Save Save to your library Print Download PDF Share Fa…

  13. Lay use of lasers fueling complications. | PSNet

    psnet.ahrq.gov/issue/lay-use-lasers-fueling-complications
    June 28, 2006 - Newspaper/Magazine Article Lay use of lasers fueling complications. Citation Text: Lay use of lasers fueling complications. Gagnon L. Dermatology Times. June 1, 2005. Copy Citation Save Save to your library Print Download PDF Share Face…

  14. 8 ways to prevent medication errors in kids. | PSNet

    psnet.ahrq.gov/issue/8-ways-prevent-medication-errors-kids
    September 28, 2016 - Newspaper/Magazine Article 8 ways to prevent medication errors in kids. Citation Text: 8 ways to prevent medication errors in kids. Payne JW. US News & World Report. May 3, 2010. Copy Citation Save Save to your library Print Download PDF Sh…

  15. Patients taking their own medications while in the hospital. | PSNet

    psnet.ahrq.gov/issue/patients-taking-their-own-medications-while-hospital
    March 14, 2012 - Newspaper/Magazine Article Patients taking their own medications while in the hospital. Citation Text: Patients taking their own medications while in the hospital. PA-PSRS Patient Saf Advis. June 2012;9:50-57.  Copy Citation Save Save to your library …

  16. Developing an adverse event reporting system using administrative data. | PSNet

    psnet.ahrq.gov/issue/developing-adverse-event-reporting-system-using-administrative-data
    September 23, 2009 - Study Developing an adverse event reporting system using administrative data. Citation Text: Developing an adverse event reporting system using administrative data. Bahl V; Thompson MA; Commisky EL; Anderson S; Campbell DA Jr. Copy Citation Save Save to your …

  17. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…

  18. Palliative Care: Comfort vs. Harm | PSNet

    psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
    December 04, 2016 - SPOTLIGHT CASE Palliative Care: Comfort vs. Harm Citation Text: Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…

  19. Lap Burn | PSNet

    psnet.ahrq.gov/web-mm/lap-burn
    March 01, 2018 - Lap Burn Citation Text: Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49387/psn-pdf
    February 01, 2003 - Patient Mix-Up February 1, 2003 Shojania KG. Patient Mix-Up. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/patient-mix The Case Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general medical service at an academic medical center. Overnight, another man wit…
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