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8701. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73860/psn-pdf
      September 22, 2021 - A system safety approach to assessing risks in the sepsis treatment process. September 22, 2021 Kaya GK. A system safety approach to assessing risks in the sepsis treatment process. Appl Ergon. 2021;94:103408. doi:10.1016/j.apergo.2021.103408. https://psnet.ahrq.gov/issue/system-safety-approach-assessing-risks-sep…

8702. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44978/psn-pdf
      June 01, 2016 - Josie's Story: A Patient Safety Curriculum. June 1, 2016 Kaprielian VS, Sullivan DT, eds. Chapel Hill, NC: Josie King Foundation; Duke University School of Medicine; 2013. https://psnet.ahrq.gov/issue/josies-story-patient-safety-curriculum The experience of Sorrel King and the death of her daughter has motivated h…

8703. Building Safety Culture and Strengthening Hospital Safety Systems | PSNet
      psnet.ahrq.gov/training-catalog/building-safety-culture-and-strengthening-hospital-safety-systems
      July 07, 2025 - Building Safety Culture and Strengthening Hospital Safety Systems Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization Hospital Quality Institute E…

8704. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867772/psn-pdf
      September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocl. September 1, 2013 Agency for Healthcare Research and Quality. Universal ICU Decolonization: An Enhanced Protocol. https://psnet.ahrq.gov/issue/universal-icu-decolonization-enhanced-protocl Methicillin-resistant?Staphylococcus aureus (MRSA) is a known threat to pati…

8705. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42581/psn-pdf
      July 12, 2016 - Partnering with Patients to Drive Shared Decisions, Better Value, and Care Improvement—Workshop Proceedings. July 12, 2016 Roundtable on Value and Science Driven Healthcare; Institute of Medicine. Washington, DC: National Academies Press; 2013. ISBN: 9780309288965. https://psnet.ahrq.gov/issue/partnering-patients-…

8706. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45926/psn-pdf
      May 17, 2017 - Toolkit To Improve Safety in Ambulatory Surgery Centers. May 17, 2017 Rockville, MD: Agency for Healthcare Research and Quality; December 2014. https://psnet.ahrq.gov/issue/toolkit-improve-safety-ambulatory-surgery-centers Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws fr…

8707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37752/psn-pdf
      May 07, 2019 - Guidance for the Safe Use of Automated Dispensing Cabinets. May 7, 2019 Horsham, PA: Institute for Safe Medication Practices; 2019. https://psnet.ahrq.gov/issue/guidance-safe-use-automated-dispensing-cabinets Drug dispensing systems have been adopted in hospitals to prevent medication errors, but accidents associ…

8708. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60527/psn-pdf
      May 27, 2020 - The flaw of medicine: addressing racial and gender disparities in critical care. May 27, 2020 Hilton EJ, Goff KL, Sreedharan R, et al. The flaw of medicine: addressing racial and gender disparities in critical care. Anesthesiol Clin. 2020;38(2):357-368. doi:10.1016/j.anclin.2020.01.011. https://psnet.ahrq.gov/issu…

8709. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42157/psn-pdf
      April 22, 2013 - High performance teamwork training and systems redesign in outpatient oncology. April 22, 2013 Bunnell CA, Gross AH, Weingart SN, et al. High performance teamwork training and systems redesign in outpatient oncology. BMJ Qual Saf. 2013;22(5):405-13. doi:10.1136/bmjqs-2012-000948. https://psnet.ahrq.gov/issue/high-…

8710. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49719/psn-pdf
      September 01, 2014 - No BP During NIBP September 1, 2014 Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/no-bp-during-nibp The Case An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization laboratory under general endotracheal anes…

8711. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49769/psn-pdf
      September 01, 2016 - Complaints as Safety Surveillance September 1, 2016 Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance The Case A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain came on sudden…

8712. An Easily Forgotten Tube | PSNet
      psnet.ahrq.gov/web-mm/easily-forgotten-tube
      June 01, 2016 - An Easily Forgotten Tube Citation Text: Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

8713. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49734/psn-pdf
      May 01, 2015 - Departure From Central Line Ritual May 1, 2015 Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/departure-central-line-ritual The Case A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…

8714. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
      May 01, 2015 - PowerPoint Presentation Spotlight Errors in Sepsis Management This presentation is based on the May 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF) Editor, AHRQ WebM&M: Rober…

8715. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49713/psn-pdf
      June 01, 2014 - CVC Removal: A Procedure Like Any Other June 1, 2014 Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other The Case A 27-year-old man with a history of Behçet disease and recurrent liver abscesses was admitted to the hospital for a p…

8716. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33650/psn-pdf
      May 01, 2007 - Patient Safety in the United Kingdom: Evolution and Progress May 1, 2007 Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evolution and Progress. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress Perspective The dangers of health care in B…

8717. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49466/psn-pdf
      October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …

8718. Benefits vs. Risks of Intraosseous Vascular Access | PSNet
      psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
      September 01, 2005 - Benefits vs. Risks of Intraosseous Vascular Access Citation Text: Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Go…

8719. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33699/psn-pdf
      August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers August 1, 2010 Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers Perspective Academic medical…

8720. Procedural Mishap: Learning Curve? | PSNet
      psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
      April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. 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 En…