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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - Unintended Consequences of CPOE
October 1, 2016
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
Case Objectives
Explain how technology, including computerized provider order entry, can transform, rather than
eliminate, hazards.
Recogni…
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound
and Patient Safety
July 1, 2018
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
Case Objectives
Unders…
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psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - Mobility Lost in the ICU
October 1, 2011
Smith J. Mobility Lost in the ICU. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/mobility-lost-icu
Case Objectives
Describe the role of the physical therapist in the hospital and ICU.
Compare the risks from immobility with the benefits gained from a program of ther…
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psnet.ahrq.gov/node/841305/psn-pdf
January 27, 2023 - In Conversation with... Ellen Deutsch, MD, MS, FACS,
FAAP, FSSH, CPPS
December 14, 2022
In Conversation with.. Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
Editor’s Note: Ellen Deutsch, MD, MS, FACS, F…
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psnet.ahrq.gov/node/49738/psn-pdf
August 21, 2015 - Privacy or Safety?
August 21, 2015
Halamka JD, McGraw D. Privacy or Safety? PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/privacy-or-safety
Case Objectives
Understand that the HIPAA Omnibus Rule is an enabler of data sharing, not a barrier.
Review common misconceptions about privacy rules.
Understand the…
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psnet.ahrq.gov/node/33842/psn-pdf
January 01, 2018 - Assessing the Safety of Electronic Health Records: What
Have We Learned?
September 1, 2017
Sittig DF, Singh H. Assessing the Safety of Electronic Health Records: What Have We Learned? PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
Perspec…
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psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?
Citation Text:
Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - Retained Surgical Items: Definition and Epidemiology.
Citation Text:
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
Citation Text:
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…
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psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures
Citation Text:
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
…
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psnet.ahrq.gov/issue/network-patient-safety-databases
December 24, 2008 - Database/Directory
Network of Patient Safety Databases.
Citation Text:
Network of Patient Safety Databases. Agency for Healthcare Research and Quality.
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psnet.ahrq.gov/issue/learning-health-systems
December 24, 2008 - Multi-use Website
Learning Health Systems
Citation Text:
Learning Health Systems Agency for Health Research and Quality.
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…
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psnet.ahrq.gov/issue/acog-committee-opinion-464-patient-safety-surgical-environment
July 18, 2019 - Commentary
ACOG Committee Opinion #464: patient safety in the surgical environment.
Citation Text:
Committee Opinion No. 464: Patient Safety in the Surgical Environment. Obstetrics & Gynecology. 2010;116(3). doi:10.1097/aog.0b013e3181f69b22.
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Format:
DOI Goog…
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psnet.ahrq.gov/issue/sentinel-event-alert-63-optimizing-smart-infusion-pump-safety-ders
March 22, 2023 - Sentinel Event Alerts
Sentinel Event Alert 63: optimizing smart infusion pump safety with DERS.
Citation Text:
Sentinel Event Alert 63: Optimizing Smart Infusion Pump Safety with DERS. Jt Comm J Qual Patient Saf. 2021;47(6):394-397. doi:10.1016/j.jcjq.2021.03.013.
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For…
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psnet.ahrq.gov/issue/antimicrobial-stewardship
October 24, 2018 - Special or Theme Issue
Antimicrobial Stewardship.
Citation Text:
Antimicrobial Stewardship. Cunha CB, ed. Med Clin North Am. 2018;102(5):797-976.
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psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss
June 15, 2024 - Commentary
Wrong site surgery: a critical incident analysis of a near miss.
Citation Text:
Tichanow S. Wrong site surgery: A critical incident analysis of a near miss. J Perioper Pract. 2016;26(1-2):11-5.
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psnet.ahrq.gov/issue/why-pay-mistakes
July 20, 2011 - Newspaper/Magazine Article
Why pay for mistakes?
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September 5, 2007
View more articles from the same authors.
Recently, CMS ru…
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psnet.ahrq.gov/issue/navigating-perfect-storm-balancing-culture-safety-workforce-challenges
May 04, 2015 - Meeting/Conference Proceedings
Navigating the perfect storm: balancing a culture of safety with workforce challenges.
Citation Text:
Navigating the perfect storm: balancing a culture of safety with workforce challenges. J Nurs Res. 2008;57(1):1-68.
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psnet.ahrq.gov/issue/who-collaborating-centres-patient-safety
April 06, 2016 - Multi-use Website
Global Patient Safety Collaborative.
Citation Text:
Global Patient Safety Collaborative. World Alliance for Patient Safety; World Health Organization
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psnet.ahrq.gov/node/48097/psn-pdf
July 17, 2019 - Serious misdiagnosis-related harms in malpractice
claims: the "Big Three": vascular events, infections, and
cancers.
July 17, 2019
Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice
claims: The “Big Three” – vascular events, infections, and cancers. Diagnosis (Berl). …