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7541. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45583/psn-pdf
      January 18, 2017 - ASHP IV Adult Continuous Infusions. January 18, 2017 Bethesda, MD: American Society of Health-System Pharmacists; 2016. https://psnet.ahrq.gov/issue/ashp-iv-adult-continuous-infusions Miscalculations of intravenous infusion concentrations can result in patient harm. Representing the first phase of a standards deve…

7542. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43435/psn-pdf
      August 06, 2014 - Trail of medical missteps in a Peace Corps death. August 6, 2014 Stolberg SG. https://psnet.ahrq.gov/issue/trail-medical-missteps-peace-corps-death Raising concerns about health care provided by the Peace Corps, this newspaper article outlines an investigation into failures, such as cognitive biases and poor judgm…

7543. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36950/psn-pdf
      September 09, 2011 - Integrating quality and safety content into clinical teaching in the acute care setting. September 9, 2011 Day L, Smith EL. Integrating quality and safety content into clinical teaching in the acute care setting. Nurs Outlook. 2007;55(3). doi:10.1016/j.outlook.2007.03.002. https://psnet.ahrq.gov/issue/integrating-…

7544. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39826/psn-pdf
      September 08, 2010 - Communicating After Harm in Healthcare. September 8, 2010 Communication Advisory Committee. Edmonton, AB, Canada: Canadian Patient Safety Institute; 2010. ISBN: 9781926541266 https://psnet.ahrq.gov/issue/guidelines-informing-media-after-adverse-event This guideline provides an organizational strategy, flow charts,…

7545. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35949/psn-pdf
      May 24, 2006 - Implementation of patient safety initiatives in US hospitals. May 24, 2006 McFadden KL, Stock GN, Gowen CR. Implementation of patient safety initiatives in US hospitals. Int J Oper Prod Manag. 2006;26(3):326-347. doi:10.1108/01443570610651052. https://psnet.ahrq.gov/issue/implementation-patient-safety-initiatives-…

7546. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37428/psn-pdf
      March 28, 2012 - A team training program using human factors to enhance patient safety. March 28, 2012 Marshall DA, Manus DA. A Team Training Program Using Human Factors to Enhance Patient Safety. AORN J. 2007;86(6). doi:10.1016/j.aorn.2007.11.026. https://psnet.ahrq.gov/issue/team-training-program-using-human-factors-enhance-pati…

7547. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39711/psn-pdf
      July 28, 2010 - Revisiting old slides—how worthwhile is it? July 28, 2010 Agarwal S, Wadhwa N. Revisiting old slides--how worthwhile is it? Pathol Res Pract. 2010;206(6):368-71. doi:10.1016/j.prp.2010.01.006. https://psnet.ahrq.gov/issue/revisiting-old-slides-how-worthwhile-it This study reviewed more than 2400 surgical pathology…

7548. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38618/psn-pdf
      May 06, 2009 - Tubing safety in the obstetric setting: preventing medication errors. May 6, 2009 Broussard BS. Tubing safety in the obstetric setting: preventing medication errors. Nurs Womens Health. 2009;13(2):155-158. doi:10.1111/j.1751-486X.2009.01407.x. https://psnet.ahrq.gov/issue/tubing-safety-obstetric-setting-preventing…

7549. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40593/psn-pdf
      July 20, 2011 - Before you make that big decision... July 20, 2011 Kahneman D, Lovallo D, Sibony O. Before you make that big decision.. Harv Bus Rev. 2011;89(6):50-60, 137. https://psnet.ahrq.gov/issue/you-make-big-decision This commentary, whose first author won a Nobel prize for his seminal work on cognitive shortcuts that und…

7550. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37476/psn-pdf
      September 29, 2017 - Work-arounds in health care settings: literature review and research agenda. September 29, 2017 Halbesleben JRB, Wakefield DS, Wakefield BJ. Work-arounds in health care settings: literature review and research agenda. Health Care Manage Rev. 2008;33(1):2-12. doi:10.1097/01.hmr.0000304495.95522.ca. https://psnet.ah…

7551. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34138/psn-pdf
      January 20, 2016 - National Quality Forum. January 20, 2016 1099 14th Street NW, Suite 500, Washington DC 20005. https://psnet.ahrq.gov/issue/national-quality-forum The National Quality Forum (NQF) is a private, not-for-profit membership organization created to develop and implement a national strategy for quality and safety measure…

7552. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35354/psn-pdf
      September 28, 2005 - Crew resource management training--clinicians' reactions and attitudes. September 28, 2005 France DJ, Stiles RA, Gaffney FA, et al. Crew resource management training-Clinicians' reactions and attitudes. AORN J. 2006;82(2):213-224. doi:10.1016/s0001-2092(06)60313-x. https://psnet.ahrq.gov/issue/crew-resource-manage…

7553. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41695/psn-pdf
      July 19, 2017 - ACOG Committee Opinion #531: improving medication safety. July 19, 2017 Improvement C on PS and Q. Committee opinion No. 531: improving medication safety. Obstet Gynecol. 2012;120(2 Pt 1):406-410. doi:10.1097/AOG.0b013e3182680478. https://psnet.ahrq.gov/issue/acog-committee-opinion-531-improving-medication-safety …

7554. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33871/psn-pdf
      December 22, 2018 - Maternal Safety December 22, 2018 Lyndon A. Maternal Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/maternal-safety Annual Perspective 2018 The Context of Maternal Safety Childbirth-related maternal health outcomes have been worsening for some time in the United States. After a dramatic reduc…

7555. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49464/psn-pdf
      December 27, 2020 - Lap Burn October 1, 2004 Ball K. Lap Burn. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lap-burn The Case A woman was scheduled for an elective diagnostic laparoscopy for dysfunctional uterine bleeding. After accessing the abdomen with the trocar without complication, the surgeon inserted the laparoscope…

7556. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.242_slideshow.ppt
      June 01, 2011 - Spotlight Case July 2008 Spotlight Case The ECG is Not Normal * * Source and Credits This presentation is based on the June 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Abigail Zuger, MD, Columbia University Editor, AHRQ WebM&M: Robe…

7557. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49652/psn-pdf
      May 01, 2012 - Double Dose at Transfer May 1, 2012 Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/double-dose-transfer The Case A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythe…

7558. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.221_slideshow.ppt
      July 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Weighing in on Surgical Safety * * Source and Credits This presentation is based on the July 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jay B. Brodsky, MD, Stanford University Medical Cente…

7559. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841306/psn-pdf
      December 14, 2022 - Resilient Healthcare and the Safety-I and Safety-II Frameworks December 14, 2022 Deutsch ES, Van CM, Mossburg SE. Resilient Healthcare and the Safety-I and Safety-II Frameworks. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks Resilient healthca…

7560. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
      September 01, 2011 - Spotlight Case July 2008 Spotlight Case The Safety and Quality of Long Term Care * * Source and Credits This presentation is based on the September 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Amy A. Vogelsmeier, PhD, RN, GCNS-BC, Uni…