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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE
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Apri…
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psnet.ahrq.gov/node/33567/psn-pdf
June 15, 2024 - Handoffs
June 15, 2024
Handoffs and Signouts. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/handoffs
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Backgroun…
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psnet.ahrq.gov/perspective/conversation-lucian-leape-md
June 12, 2019 - So when these hospitals said they wanted to try this, they had very extensive requirements for participation
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - questions will be conducted at the start and conclusion of the
presentation – we would appreciate your participation
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - studies describing reduced risky behaviors following HIV diagnosis are difficult to interpret due to low participation
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - April 20, 2022
Impact of resident participation in surgical operations on postoperative
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
April 01, 2006 - Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - delirium or reduced cognitive function, increasing their risk of falls, malnutrition, and limiting their participation
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - delirium or reduced cognitive function, increasing their risk of falls, malnutrition, and limiting their participation
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.
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psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - We have been involving patients in patient participation and/or patient empowerment strategies for some
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psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
“This is the wrong patient’s blood!”:
Evaluating a Near-Miss Wrong
Transfusion Event
Source and Credits
• This presentation is based on the January 2020 AHRQ WebM&M
Spotlight Case
• Commentary by: Sarah Barnhard MD
o Medical Director of Transfusion Services at UC-Davis Health
o Editors in …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - Spotlight Case July 2008
Spotlight Case
Near Miss with Bedside Medications
*
*
Source and Credits
This presentation is based on the November 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Albert W. Wu, MD, MPH, Johns Hopkins Bloomberg S…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
September 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case September 2004
Poor Prognosis?
Source and Credits
This presentation is based on the September 2004
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Elizabeth B. Lamont, M…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case July 2004
Preventing Inappropriate Use of Novel Therapeutic Agents
Source and Credits
This presentation is based on the July 2004 AHRQ WebM&M Spotlight Case in Critical Care Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the W…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt
March 01, 2015 - PowerPoint Presentation
Spotlight
Two Wrongs Don't Make a Right (Kidney)
This presentation is based on the March 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John G. DeVine, MD, Professor of Orthopaedic Surgery, Medical College of Georgia
Ed…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.104_slideshow.ppt
September 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case September 2005
Double Trouble
Source and Credits
This presentation is based on the Sept. 2005
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Jerry H. Gurwitz, MD, University of…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
November 01, 2003 - Spotlight Case [MONTH] 2003
Spotlight Case November 2003
The Missing Suction Tip
Source and Credits
This presentation is based on the Nov. 2003
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Eric J. Thomas, MD,…
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psnet.ahrq.gov/node/33568/psn-pdf
June 15, 2024 - Root Cause Analysis
June 15, 2024
Root Cause Analysis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/root-cause-analysis
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…