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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - necessary items (such as call light, telephone, and water) within patient's reach Maintain bed in proper
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - Proper planning and execution of the CABG operation has been shown to prolong life by reducing rates
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psnet.ahrq.gov/node/850678/psn-pdf
June 14, 2023 - infrastructure, and standardized system
governance, which included a hospital readiness assessment and ensuring proper
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - In this case, the nephrologist should have communicated clear and specific recommendations regarding proper
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - The attending could invest time teaching the interns involved about inpatient problem triage and proper
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psnet.ahrq.gov/node/838972/psn-pdf
October 27, 2022 - The importance of a proper against-medical-advice (AMA)
discharge: how signing out AMA may create significant
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psnet.ahrq.gov/node/836978/psn-pdf
May 16, 2022 - strengthening connections between the care team and the
patient.6 Specific examples include (a) bringing the proper
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psnet.ahrq.gov/node/50696/psn-pdf
November 27, 2019 - be thoroughly screened for risk factors that may lead to complications and, if any are
identified, proper
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psnet.ahrq.gov/node/49446/psn-pdf
August 30, 2021 - Protocols for insulin drips should be created,
which clearly outline proper adjustment of the drip at
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psnet.ahrq.gov/node/33886/psn-pdf
August 01, 2019 - navigation
and functionality; computerized order entry, clinical decision support, and reminders; and proper
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psnet.ahrq.gov/web-mm/missed-compartment-syndrome-after-steep-lithotomy-position-laparoscopic-gynecological
January 29, 2021 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery
Citation Text:
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…
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psnet.ahrq.gov/node/33812/psn-pdf
August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS,
PhD
August 1, 2016
In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
Editor's note: Dr. Perea-Pérez is Director de la Escuela de Medicina Legal y For…
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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - Chemotherapy Administration Safety Standards
September 1, 2018
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
The Case
A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…
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psnet.ahrq.gov/node/49435/psn-pdf
February 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…
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psnet.ahrq.gov/node/33681/psn-pdf
March 01, 2009 - The Role of Health Literacy in Patient Safety
March 1, 2009
Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
Perspective
Clear health communication is increasingly recognized as essential for promoting …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
December 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case December 2007
Elopement
Source and Credits
This presentation is based on the December 2007 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Debra Gerardi, RN, MPH, JD
Creighton University School of Law
Ed…
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Medication Errors and Adverse Drug Events
Citation Text:
Medication Errors and Adverse Drug Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote…
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - may bring about confusion and unexpected consequences, but the effort holds the promise of ensuring proper
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Resource management can be key to preventing a significant shortage from affecting proper patient care
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - and family with an apology, and (iii) in the course of the RCA, determination of
how a nurse without proper