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psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
July 01, 2006 - January 2, 2017
WebM&M Cases
Good Catch in the Operating … Room
May 1, 2019
WebM&M Cases
Turn the Other
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psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
September 01, 2008 - as prohibiting the use of neuromuscular blocking agents outside of intensive care units [ICUs] and operating … room settings).
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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - A Weighty Mistake
March 1, 2013
Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/weighty-mistake
Case Objectives
Understand factors associated with weight-based dosing medication errors in pediatric populations.
Describe how adoption of computerized provider order entry (CPOE) s…
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating … Room
April 27, 2022
WebM&M Cases
Diagnostic
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Can be performed at the bedside without the
resources and potential delay of scheduling
time in an operating … room
Should be considered in patients with morbid
obesity, short necks, tracheal deviation, or
impaired
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - evaluated by physicians using the focused assessment
of sonography in trauma, patients are taken to the operating … room faster.(16)
The literature offers relatively few descriptions of typical errors or pitfalls in
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psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
September 01, 2017 - March 4, 2011
From the flight deck to the operating room: an initial pilot study of the
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - WebM&M Cases
If You Say So: Taking a Syringe at Face Value in the Operating … Room
June 1, 2019
WebM&M Cases
Hip Fractures
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - In Conversation with…William B. Munier, MD, MBA
July 1, 2011
Also Read an Essay
Citation Text:
In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
March 01, 2017 - September 18, 2024
Factors associated with the use of cognitive aids in operating room
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psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
December 01, 2014 - Virtual reality training improves operating room performance: results of a randomized, double-blinded
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psnet.ahrq.gov/node/49657/psn-pdf
July 01, 2012 - Virtual reality training improves operating room
performance: results of a randomized, double-blinded
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Strategies to Improve Organizational Health Literacy.
May 31, 2023
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
Background
Health literacy is important at both the personal …
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psnet.ahrq.gov/web-mm/little-shuteye
December 22, 2018 - A Little Shuteye
Citation Text:
Farion KJ. A Little Shuteye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes
Ross Koppel, PhD | July 1, 2012
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Koppel R. Patient Safety and Health Information Technology: Learning f…
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
July 01, 2012 - EMR Entry Error: Not So Benign
Citation Text:
Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - Then we found another system where their time for wheels-in to wheels-out of the operating room for the
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Then we found another system where their time for wheels-in to wheels-out of the operating room for the
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psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
September 01, 2008 - as prohibiting the use of neuromuscular blocking agents outside of intensive care units [ICUs] and operating … room settings).