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9161. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35619/psn-pdf
      June 24, 2010 - Studying patient safety in health care organizations: accentuate the qualitative. June 24, 2010 Hoff TJ, Sutcliffe K. Studying patient safety in health care organizations: accentuate the qualitative. Jt Comm J Qual Patient Saf. 2006;32(1):5-15. https://psnet.ahrq.gov/issue/studying-patient-safety-health-care-organ…

9162. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47540/psn-pdf
      April 03, 2019 - Medication handling: towards a practical, human-centred approach. April 3, 2019 Marshall SD, Chrimes N. Medication handling: towards a practical, human-centred approach. Anaesthesia. 2019;74(3):280-284. doi:10.1111/anae.14482. https://psnet.ahrq.gov/issue/medication-handling-towards-practical-human-centred-approac…

9163. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34770/psn-pdf
      April 17, 2017 - Clinical Risk Management. Enhancing Patient Safety. 2nd ed. April 17, 2017 Vincent CA, ed. London, UK: BMJ Books; 2001. ISBN: 9780727913920. https://psnet.ahrq.gov/issue/clinical-risk-management-enhancing-patient-safety-2nd-ed Vincent has updated his text on risk management, infusing it with concepts directly rela…

9164. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37732/psn-pdf
      May 30, 2008 - Oncology care setting design and planning part I: concepts for the oncology nurse that improve patient safety. May 30, 2008 Sheridan-Leos N. Oncology care setting design and planning part I: Concepts for the oncology nurse that improve patient safety. Clin J Oncol Nurs. 2008;12(2):361-3. doi:10.1188/08.CJON.361-36…

9165. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34731/psn-pdf
      July 08, 2016 - Crossing the Quality Chasm: A New Health System for the 21st Century. July 8, 2016 Committee on Quality of Health Care in America, Institute of Medicine. Washington DC: National Academies Press; 2001. ISBN: 9780309072809. https://psnet.ahrq.gov/issue/crossing-quality-chasm-new-health-system-21st-century Following…

9166. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867449/psn-pdf
      March 13, 2025 - Medication Related Harm. March 13, 2025 Medication Related Harm. Health Services Safety Investigations Body. 2024-2025 https://psnet.ahrq.gov/issue/medication-related-harm Omitted or delayed medication therapy can contribute to patient discomfort, stress, and harm. This series of reports, to be developed over 2024…

9167. 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…

9168. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49422/psn-pdf
      November 01, 2003 - 40 of K November 1, 2003 Lesar TS. 40 of K. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/40-k The Case An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…

9169. 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…

9170. 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…

9171. 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…

9172. 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…

9173. 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…

9174. 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…

9175. 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, …

9176. 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…

9177. 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…

9178. 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…

9179. Coming Up Short | PSNet
      psnet.ahrq.gov/web-mm/coming-short
      May 20, 2020 - Coming Up Short Citation Text: Hochberg Z'ev. Coming Up Short. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

9180. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49412/psn-pdf
      September 01, 2003 - Shake Well September 1, 2003 Flynn EA. Shake Well. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/shake-well The Case A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily serum drug levels consistently fell below the therapeutic range, which led the physi…