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6821. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37372/psn-pdf
      August 06, 2008 - Hospitals look to improve informed consent process. August 6, 2008 O'Reilly KB. https://psnet.ahrq.gov/issue/hospitals-look-improve-informed-consent-process This article discusses the impact of health literacy on patient care and describes initiatives to improve patients' comprehension of informed consent for proc…

6822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35582/psn-pdf
      June 17, 2010 - Building a safety culture. June 17, 2010 Milligan F, Dennis S. Building a safety culture. Nurs Stand. 2005;20(11):48-52. https://psnet.ahrq.gov/issue/building-safety-culture The authors provide an introduction to British patient safety efforts for nurses and midwives and emphasize the importance of supporting a ju…

6823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36574/psn-pdf
      March 09, 2009 - Studying organisational cultures and their effects on safety. March 9, 2009 Hopkins A. Studying organisational cultures and their effects on safety. Saf Sci. 2006;44(10). doi:10.1016/j.ssci.2006.05.005. https://psnet.ahrq.gov/issue/studying-organisational-cultures-and-their-effects-safety The author shares exampl…

6824. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35665/psn-pdf
      March 18, 2010 - Clear liquids may place patients at risk. March 18, 2010 Pennsylvania Patient Safety Reporting System. https://psnet.ahrq.gov/issue/clear-liquids-may-place-patients-risk Using reports submitted to the Pennsylvania Patient Safety Reporting System, this advisory cautions against using unlabeled clear liquids and pro…

6825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36440/psn-pdf
      November 22, 2006 - VA Interprofessional Fellowship Program in Patient Safety. November 22, 2006 National Center for Patient Safety. https://psnet.ahrq.gov/issue/va-interprofessional-fellowship-program-patient-safety This program provides 12 placements for a 1-year post-advanced degree educational opportunity at six Veterans Adminis…

6826. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35249/psn-pdf
      March 04, 2011 - The patient safety story. March 4, 2011 Elwyn G, Corrigan JM. The patient safety story. BMJ. 2005;331(7512):302-304. doi:10.1136/bmj.38562.690104.43. https://psnet.ahrq.gov/issue/patient-safety-story The authors provide a brief history of the patient safety movement and insights into why the time is right to impl…

6827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35506/psn-pdf
      June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR. https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-1 This monthly selection of medication error reports provides examples of drug misadministration, confusion with drug names, and administration of chemotherapy to the wrong patient, plu…

6828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38214/psn-pdf
      January 27, 2015 - Windows into Safety and Quality in Health Care 2008. January 27, 2015 Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2008. ISBN: 9780980346275. https://psnet.ahrq.gov/issue/windows-safety-and-quality-health-care-2008 This report compiles public and private data to provide insight in…

6829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40828/psn-pdf
      September 02, 2016 - Examining the Increase in Drug Shortages. September 2, 2016 Hearings before the Subcommittee on Health of the Committee on Energy and Commerce Committee, 112th Cong, 1st Sess (September 23, 2011). https://psnet.ahrq.gov/issue/examining-increase-drug-shortages This hearing focused on the problem of medication short…

6830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49471/psn-pdf
      December 01, 2004 - Carpe Diem (Seize the Day) December 1, 2004 Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day The Case A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic medical conditions including hypertension, h…

6831. Spotlight (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.ppt
      November 01, 2018 - Spotlight Spotlight Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees * Source and Credits This presentation is based on the November 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Olle ten C…

6832. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33874/psn-pdf
      February 01, 2019 - Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula February 1, 2019 Gonzalo JD, Singh MK. Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula. PSNet [internet]. 2019. https://psnet.…

6833. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49742/psn-pdf
      September 01, 2015 - A Fumbled Handoff to Inpatient Rehab September 1, 2015 Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab The Case An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…

6834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33687/psn-pdf
      August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care August 1, 2009 Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care Perspective Frontline health care providers are challen…

6835. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49695/psn-pdf
      October 01, 2013 - Finding Fault With the Default Alert October 1, 2013 Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/finding-fault-default-alert The Case A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital after experiencing …

6836. Medication Errors and Adverse Drug Events | PSNet
      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…

6837. Patient Safety and Opioid Medications | PSNet
      psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
      January 01, 2015 - Annual Perspective Patient Safety and Opioid Medications Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2016  View more articles from the same authors. Citation Text: Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. Ro…

6838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42549/psn-pdf
      August 28, 2013 - Patient safety: threats and solutions. August 28, 2013 McCaughan D, Kaufman G. Patient safety: threats and solutions. Nurs Stand. 2013;27(44):48-55; quiz 56, 58. https://psnet.ahrq.gov/issue/patient-safety-threats-and-solutions This commentary provides an overview of patient safety, including types of adverse even…

6839. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37085/psn-pdf
      July 15, 2013 - Critical Care Safety: Essentials for ICU Patient Care and Technology. July 15, 2013 Plymouth Meeting PA: ECRI Institute; 2007. ISBN 9780977914258. https://psnet.ahrq.gov/issue/critical-care-safety-essentials-icu-patient-care-and-technology This guide provides comprehensive tools for assessment, training, and imple…

6840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36472/psn-pdf
      January 07, 2011 - Communication devices in the operating room. January 7, 2011 Ruskin KJ. Communication devices in the operating room. Curr Opin Anaesthesiol. 2006;19(6):655-9. https://psnet.ahrq.gov/issue/communication-devices-operating-room The author discusses technologies such as cellular phones, wireless Ethernet, and voice ove…