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5221. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836878/psn-pdf
      April 27, 2022 - The Media’s Role in Patient Safety April 27, 2022 Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/medias-role-patient-safety Brief History of the Media Influencing Patient Safety Despite studies raising questions about avoidable ha…

5222. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33641/psn-pdf
      November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again November 1, 2006 Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again Perspective Certain phrases ar…

5223. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
      November 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case November 2008 Dangerous Shift Source and Credits This presentation is based on the November 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Emily S. Patterson, PhD Institute for Ergonomics, Ohi…

5224. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33595/psn-pdf
      December 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety December 15, 2024 Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that th…

5225. Spotlight Case (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
      October 01, 2009 - Spotlight Case Spotlight Case Difficult Encounters: A CMO and CNO Respond Source and Credits This presentation is based on the October 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Ernie Ring, MD; Jane Hirsch, RN, MS UCSF Medical Cen…

5226. Rapid Response Teams: Lessons from the Early Experience | PSNet
      psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
      November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience William S. Krimsky, MD | November 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…

5227. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865466/psn-pdf
      March 27, 2024 - Equity in Patient Safety March 27, 2024 Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/equity-patient-safety Introduction Safety and equity are among the central components that determine quality of care, according to nonprofit advisory agencies l…

5228. Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective | PSNet
      psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurses-perspective
      June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective Karen Frank, DNP, RN, MSHA | June 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Frank K. Becoming a Certified Professional in Patien…

5229. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846126/psn-pdf
      March 09, 2023 - Medication Handling and Compounding Errors in the Operating Room. March 15, 2023 Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room The Case A 62-y…

5230. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49415/psn-pdf
      September 01, 2003 - Intubation Mishap September 1, 2003 Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/intubation-mishap Case Objectives To understand and apply a structured method of human factors case analysis To describe the key components of effective teamwork To understand the imp…

5231. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867497/psn-pdf
      February 26, 2025 - Retained Surgical Items: Causation and Prevention February 26, 2025 Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention Background A retained surgical item (RSI) is a surgical patient safety pro…

5232. Executive Order on the Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence. | PSNet
      psnet.ahrq.gov/issue/executive-order-safe-secure-and-trustworthy-development-and-use-artificial-intelligence
      October 05, 2022 - Government Resource Executive Order on the Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence. Citation Text: Executive Order on the Safe, Secure, and Trustworthy Development and Use of Artificial Intelligence. Washington DC: The White House; October 30, 2023.&n…

5233. Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. | PSNet
      psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-do-and-how-fix-it
      November 20, 2019 - Newspaper/Magazine Article Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Citation Text: Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Park A. Time Magazine. January 24, 2019. Copy Citation…

5234. ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology. | PSNet
      psnet.ahrq.gov/issue/acog-committee-opinion-no-447-patient-safety-obstetrics-and-gynecology
      July 19, 2017 - Commentary ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology. Citation Text: Improvement AC of O and GCC on PS and Q. ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-7. doi:10.1097/AOG.0b013e3181c6f90…

5235. Hidden danger, obvious opportunity: error and risk in the management of cancer. | PSNet
      psnet.ahrq.gov/issue/hidden-danger-obvious-opportunity-error-and-risk-management-cancer
      June 07, 2018 - Commentary Hidden danger, obvious opportunity: error and risk in the management of cancer. Citation Text: Munro AJ. Hidden danger, obvious opportunity: error and risk in the management of cancer. Br J Radiol. 2007;80(960):955-66. Copy Citation Format: Google Scholar PubMe…

5236. Blind obedience and an unnecessary workup for hypoglycemia: a teachable moment. | PSNet
      psnet.ahrq.gov/issue/blind-obedience-and-unnecessary-workup-hypoglycemia-teachable-moment
      March 14, 2022 - Commentary Blind obedience and an unnecessary workup for hypoglycemia: a teachable moment. Citation Text: Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.71…

5237. Adverse glycemic events and critical emergencies. | PSNet
      psnet.ahrq.gov/issue/adverse-glycemic-events-and-critical-emergencies
      December 14, 2022 - Newspaper/Magazine Article Adverse glycemic events and critical emergencies. Citation Text: Adverse glycemic events and critical emergencies. ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4. Copy Citation Save Save to your library …

5238. Coordination Between Emergency and Primary Care Physicians. | PSNet
      psnet.ahrq.gov/issue/coordination-between-emergency-and-primary-care-physicians
      August 13, 2014 - Book/Report Coordination Between Emergency and Primary Care Physicians. Citation Text: Coordination Between Emergency and Primary Care Physicians. Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 2011. NIHCR Research Brief No. 3. Copy Citation …

5239. Multiple latent failures align to allow a serious drug interaction to harm a patient. | PSNet
      psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient
      June 10, 2018 - Newspaper/Magazine Article Multiple latent failures align to allow a serious drug interaction to harm a patient. Citation Text: Multiple latent failures align to allow a serious drug interaction to harm a patient. ISMP Medication Safety Alert! Acute care edition. May 5, 2011;16:1-3. Co…

5240. Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). | PSNet
      psnet.ahrq.gov/issue/safety-investigations-across-pond-deep-learning-englands-healthcare-safety-investigation
      May 03, 2023 - Newspaper/Magazine Article Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). Citation Text: Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). ISMP M…