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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44687/psn-pdf
    June 21, 2016 - Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human. June 21, 2016 Boston, MA: National Patient Safety Foundation; 2015. https://psnet.ahrq.gov/issue/free-harm-accelerating-patient-safety-improvement-fifteen-years-after-err- human This report provides an objective assessmen…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34804/psn-pdf
    January 05, 2017 - Incident reporting system does not detect adverse drug events: a problem for quality improvement. January 5, 2017 Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995;21(10):541-8. https://psnet.ahrq.…

  3. Neuromuscular blocking agents: reducing associated wrong-drug errors. | PSNet

    psnet.ahrq.gov/issue/neuromuscular-blocking-agents-reducing-associated-wrong-drug-errors
    April 26, 2023 - Newspaper/Magazine Article Neuromuscular blocking agents: reducing associated wrong-drug errors. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL April 16, 2018 This article discu…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50855/psn-pdf
    January 29, 2020 - Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center. January 29, 2020 Ho S, Stamm R, Hibbs M, et al. Is One-Pen, One-Patient Achievable in the Hospital? A Quality Improvement Project to Reduce Risks …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74159/psn-pdf
    December 08, 2021 - Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues. December 8, 2021 Malevanchik L, Wheeler M, Gagliardi K, et al. Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues. . Jt Comm J Qu…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37510/psn-pdf
    March 04, 2011 - Rare adverse medical events in VA inpatient care: reliability limits to using patient safety indicators as performance measures. March 4, 2011 West AN, Weeks WB, Bagian JP. Rare adverse medical events in VA inpatient care: reliability limits to using patient safety indicators as performance measures. Health Serv R…

  7. Medication Reconciliation With a Twist (or Dare We Say, a Patch?) | PSNet

    psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
    April 03, 2024 - SPOTLIGHT CASE Medication Reconciliation With a Twist (or Dare We Say, a Patch?) Citation Text: Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849679/psn-pdf
    June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture June 28, 2023 Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49723/psn-pdf
    January 01, 2015 - Monitoring Fetal Health January 1, 2015 Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/monitoring-fetal-health Case Objectives Define fetal heart rate monitoring. Describe the current state of evidence regarding fetal heart rate monitoring. List the known …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49525/psn-pdf
    December 01, 2006 - Hidden Heparins: HIT Happens December 1, 2006 Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens Case Objectives Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication, thrombosis. Discuss the managem…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near- Miss Wrong Transfusion Event January 29, 2020 Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…

  12. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure | PSNet

    psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
    March 01, 2005 - SPOTLIGHT CASE CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure Citation Text: Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…

  13. A Sweet Case of Hidden Hydrogen Ions | PSNet

    psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
    November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions Citation Text: Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  14. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet

    psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
    September 30, 2020 - SPOTLIGHT CASE Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Citation Text: Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33573/psn-pdf
    March 15, 2025 - Disruptive and Unprofessional Behavior March 15, 2025 Disruptive and Unprofessional Behavior. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current resear…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42230/psn-pdf
    October 06, 2016 - Using Lean to improve medication administration safety: in search of the "perfect dose." October 6, 2016 Ching JM, Long C, Williams BL, et al. Using lean to improve medication administration safety: in search of the "perfect dose". Jt Comm J Qual Patient Saf. 2013;39(5):195-204. https://psnet.ahrq.gov/issue/using-…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39419/psn-pdf
    September 20, 2011 - Engaging patients as vigilant partners in safety: a systematic review. September 20, 2011 Schwappach DLB. Engaging patients as vigilant partners in safety: a systematic review. Med Care Res Rev. 2010;67(2):119-148. doi:10.1177/1077558709342254. https://psnet.ahrq.gov/issue/engaging-patients-vigilant-partners-safet…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46766/psn-pdf
    January 17, 2018 - What hinders the uptake of computerized decision support systems in hospitals? A qualitative study and framework for implementation. January 17, 2018 Liberati EG, Ruggiero F, Galuppo L, et al. What hinders the uptake of computerized decision support systems in hospitals? A qualitative study and framework for imple…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36364/psn-pdf
    February 14, 2017 - National surveillance of emergency department visits for outpatient adverse drug events. February 14, 2017 Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events. JAMA. 2006;296(15):1858-66. https://psnet.ahrq.gov/issue/national-surveil…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37392/psn-pdf
    February 15, 2011 - Health care consumers' inclination to engage in selected patient safety practices: a survey of adults in Pennsylvania. February 15, 2011 Marella WM, Finley E, Thomas AD, et al. Health Care Consumers' Inclination to Engage in Selected Patient Safety Practices. J Patient Saf. 2008;3(4). doi:10.1097/pts.0b013e31815a6…
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