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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizationsOctober 27, 2022 - Methadone's peak respiratory depressant effects typically occur later, and persist longer, than its peak … as sickle cell disease are particularly difficult to manage, as multiple transitions of care often occur
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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practiceJanuary 01, 2016 - because they just send their report back to me in the medical record and that conversation doesn't occur
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psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreementSeptember 24, 2024 - behaviors and processes that reduce the probability of experiencing errors and catching errors that occur … And when an event does occur, they focus on understanding the root causes and identifying corrective
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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/867137/psn-pdfNovember 13, 2024 - Enteral nutrition: an underappreciated source of patient safety events. November 13, 2024 Citty SW, Chew M, Hiller LD, et al. Enteral nutrition: an underappreciated source of patient safety events. Nutr Clin Prac. 2024;39(4):784-799. doi:10.1002/ncp.11153. https://psnet.ahrq.gov/issue/enteral-nutrition-underapprec… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49435/psn-pdfFebruary 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49619/psn-pdfFebruary 01, 2011 - Paradoxical Pulse February 1, 2011 Roy CL. Paradoxical Pulse. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/paradoxical-pulse The Case An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful pacemaker placement as an outpatient. The patient was restarted on … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49448/psn-pdfJune 01, 2004 - Listen to the Family June 1, 2004 Campbell D. Listen to the Family. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/listen-family The Case Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The surgical resident examined the patient, an elderly woman with … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49598/psn-pdfFebruary 01, 2010 - Medication Reconciliation Pitfalls February 1, 2010 Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls The Case A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was brought to the eme… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33644/psn-pdfDecember 01, 2006 - Establishing a Safety Culture: Thinking Small December 1, 2006 Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small Perspective Safety cultures are the holy grail in any risky industry. Like all holy grails, th… -
PowerPoint Presentation (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.pptAugust 01, 2015 - PowerPoint Presentation Spotlight Privacy or Safety? 1 This presentation is based on the July/August 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John D. Halamka, MD, MS, Beth Israel Deaconess Medical Center; and Deven McGraw, JD, MPH, LLM… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33829/psn-pdfMarch 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety March 1, 2017 Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866217/psn-pdfJuly 10, 2024 - In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives July 10, 2024 Helwig A, Sousane Z, Mossburg S. In Conversation With..Amy Helwig about Health Plan Patient Safety Initiatives. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patie… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33827/psn-pdfFebruary 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS February 1, 2017 Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps Perspective Ten years ago, the Ag… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/50697/psn-pdfNovember 27, 2019 - Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation November 27, 2019 Kulig CE, Ebong IA. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation The Case A 36-year-old woman with a history of dep… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866265/psn-pdfJuly 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport July 31, 2024 MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49866/psn-pdfJune 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866395/psn-pdfJuly 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… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73067/psn-pdfMarch 24, 2021 - Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths. March 24, 2021 LaGrone LN, McIntyre LK, Riggle A, et al. Changes in error patterns in unanticipated trauma deaths during 20 years: In pursuit of zero preventable deaths. J Trauma Acute Care Surg. 2020;89… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/38360/psn-pdfMarch 18, 2010 - Medication errors occurring with the use of bar-code administration technology. March 18, 2010 PA-PSRS Patient Saf Advis. December 2008;5:122-126. https://psnet.ahrq.gov/issue/medication-errors-occurring-use-bar-code-administration-technology This article describes errors associated with bar coded medication admin… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73603/psn-pdfAugust 18, 2021 - The patients' perspective: hematological cancer patients' experiences of adverse events as part of care. August 18, 2021 Bryant J, Carey M, Sanson-Fisher R, et al. The patients' perspective: hematological cancer patients' experiences of adverse events as part of care. J Patient Saf. 2021;17(5):e387-e392. doi:10.10…
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