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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50750/psn-pdf
    January 01, 2020 - Patterns in medication incidents: a 10-yr experience of a cross-national anaesthesia incident reporting system. December 18, 2019 Sanduende-Otero Y, Villalón-Coca J, Romero-García E, et al. Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system. Br J Anaesth. …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60030/psn-pdf
    March 11, 2020 - Soft factors, smooth transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care. March 11, 2020 Latzke M, Schiffinger M, Zellhofer D, et al. Soft Factors, Smooth Transport? The role of safety climate and team processes in reducing adverse ev…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850933/psn-pdf
    June 21, 2023 - The prevalence of second victim syndrome and emotional distress in pediatric intensive care providers. June 21, 2023 Wolf MS, Smith K, Basu M, et al. The prevalence of second victim syndrome and emotional distress in pediatric intensive care providers. J Pediatr Intensive Care. 2023;12(02):125-130. doi:10.1055/s-00…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74134/psn-pdf
    December 01, 2021 - Remember that patient you saw last week: characteristics and frequency of patients experiencing anticipated and unanticipated death following ED discharge. December 1, 2021 Hoang R, Sampsel K, Willmore A, et al. Remember that patient you saw last week: characteristics and frequency of patients experiencing anticip…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49615/psn-pdf
    December 01, 2010 - ulcers, when they should also be used for high-risk individuals on the "'front end"—before an ulcer occurs
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49393/psn-pdf
    April 01, 2003 - Which End Is Which? April 1, 2003 Campbell AR. Which End Is Which? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/which-end-which The Case A 39-year-old woman with chronic peri-anal fistulas and infected anal sinuses underwent laparoscopic diverting colostomy to divert her fecal stream and allow the perine…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49845/psn-pdf
    October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages October 1, 2018 Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages The Case A 1-month-old preterm infant in the ne…
  8. psnet.ahrq.gov/issue/heed-warning-dont-miss-important-computer-alerts
    May 07, 2018 - Newspaper/Magazine Article Heed this warning! Don't miss important computer alerts. Citation Text: Heed this warning! Don't miss important computer alerts. ISMP Medication Safety Alert! Acute Care Edition. February 8, 2007;12:1-2. Copy Citation Save Save to your l…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49482/psn-pdf
    May 01, 2005 - intimal tear originating within 2 cm of the aortic valve in 75% of cases.( 7) The aortic tear commonly occurs
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47502/psn-pdf
    June 02, 2019 - Failure to debrief after critical events in anesthesia is associated with failures in communication during the event. June 2, 2019 Arriaga AF, Sweeney RE, Clapp JT, et al. Failure to Debrief after Critical Events in Anesthesia Is Associated with Failures in Communication during the Event. Anesthesiology. 2019;130(…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49714/psn-pdf
    August 21, 2014 - Microbial invasion of the subcutaneous tissues occurs either through external trauma (often seen in … The local pain is replaced by numbness, which occurs from compression or infarction of the nerves.
  12. psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
    September 01, 2016 - individuals to make mistakes and (ii) to permit the detection and correction of errors before harm occurs … • Prevent malfunctioning or unintentional operation by reverting back to a safe state if failure occurs
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49591/psn-pdf
    October 01, 2009 - When this occurs, implementing corrective action is very difficult and time consuming and must follow … I fully realize that the kind of rude behavior displayed by the resident in this case still occurs sometimes—even
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49525/psn-pdf
    December 01, 2006 - Heparin-induced thrombocytopenia (HIT) occurs when heparin molecules stimulate formation of a pathogenic … following use of intravenous heparin.(11) In contrast, coumarin-induced skin necrosis (CISN) rarely occurs
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33777/psn-pdf
    January 01, 2015 - and teaches others, rather than creating a separate, centralized structure where innovative thinking occurs
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33641/psn-pdf
    November 01, 2006 - How can we harness the surprise that occurs when a provider or leader takes on a human factors engineering
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40745/psn-pdf
    September 07, 2011 - A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. September 7, 2011 Li P, Stelfox HT, Ghali WA. A Prospective Observational Study of Physician Handoff for Intensive-Care- Unit-to-Ward Patient Transfers. Am J Med. 2011;124(9). doi:10.1016/j.amjmed.2011.04.027. …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60977/psn-pdf
    January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication September 30, 2020 Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication The Case A 65-year-old woman co…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73109/psn-pdf
    April 07, 2021 - Common general surgical never events: analysis of NHS England never event data. April 7, 2021 Omar I, Singhal R, Wilson M, et al. Common general surgical never events: analysis of NHS England never event data. Int J Qual Health Care. 2021;33(1):mzab045. doi:10.1093/intqhc/mzab045. https://psnet.ahrq.gov/issue/comm…
  20. psnet.ahrq.gov/web-mm/one-ace-too-many
    June 21, 2016 -   Succinylcholine   Trimethoprim Amiloride-like effect on distal tubule; occurs

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