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2301. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49844/psn-pdf
      October 01, 2018 - Diffusion of Responsibility Leads to Danger October 1, 2018 Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger The Case A 70-year-old man was sent to the emergency department (ED) from a nursing facility…

2302. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49596/psn-pdf
      December 01, 2009 - Round-Trip Service December 1, 2009 McGrath MH. Round-Trip Service. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/round-trip-service The Case A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms in his left knee. He was referred by his primary care provid…

2303. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49724/psn-pdf
      January 01, 2015 - Bowel Injury After Laparoscopic Surgery January 1, 2015 Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery The Case A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mes…

2304. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49782/psn-pdf
      January 01, 2017 - A Potent Medication Administered in a Not So Viable Route January 1, 2017 Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route The Case A 55-year-old man with history of nonischemic cardiomyop…

2305. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865467/psn-pdf
      March 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences March 27, 2024 Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc…

2306. Back to Basics | PSNet
      psnet.ahrq.gov/web-mm/back-basics
      July 13, 2010 - Back to Basics Citation Text: Hellman R. Back to Basics. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

2307. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49802/psn-pdf
      August 01, 2017 - Add-on Case and the Missing Checklist August 1, 2017 Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/add-case-and-missing-checklist The Case A 65-year-old woman was admitted for evaluation of abdominal pain and weight loss. Based on diagnostic data and ima…

2308. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840255/psn-pdf
      November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions November 16, 2022 Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions . PSNet [internet]. 2022. https://psnet.ahrq.gov/perspecti…

2309. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49788/psn-pdf
      March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention March 1, 2017 Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention The Case A 48-year…

2310. Patient Mix-Up | PSNet
      psnet.ahrq.gov/web-mm/patient-mix
      December 01, 2007 - Patient Mix-Up Citation Text: Shojania KG. Patient Mix-Up. 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 EndNote 7 XML Endnote tagged PubMedId RIS …

2311. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
      June 01, 2013 - Spotlight Case July 2008 Spotlight Case Emergency Error 1 2 Source and Credits This presentation is based on the June 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London Editor, AHRQ WebM&M: Robe…

2312. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport | PSNet
      psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
      March 12, 2021 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport Citation Text: MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…

2313. Timely diagnosis of esophageal perforation | PSNet
      psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
      September 27, 2023 - Timely diagnosis of esophageal perforation Citation Text: Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX …

2314. Wrong Route for Nutrients | PSNet
      psnet.ahrq.gov/web-mm/wrong-route-nutrients
      September 04, 2010 - Wrong Route for Nutrients Citation Text: Scott-Cawiezell JR. Wrong Route for Nutrients. 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 Endno…

2315. Weekly Resource | PSNet
      psnet.ahrq.gov/periodic-issue/weekly-resource
      March 25, 2025 - March 12, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports,…

2316. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33600/psn-pdf
      June 16, 2024 - Patient Safety 101 June 16, 2024 Patient Safety 101. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/patient-safety-101 PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in…

2317. Rescue Improvement Conference Innovation Summary | PSNet
      psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
      September 23, 2024 - Rescue Improvement Conference Innovation Summary Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 23, 2024 View more articles from the same authors. Innovation Contact …

2318. Rapid Mis-St(r)ep | PSNet
      psnet.ahrq.gov/web-mm/rapid-mis-strep
      February 01, 2004 - Rapid Mis-St(r)ep Citation Text: Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

2319. Fumbled Handoff | PSNet
      psnet.ahrq.gov/web-mm/fumbled-handoff
      September 01, 2006 - Fumbled Handoff Citation Text: Vidyarthi A. Fumbled Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

2320. In Conversation With… Edward Kelley, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
      December 01, 2014 - In Conversation With… Edward Kelley, PhD December 1, 2014  Also Read an Essay Citation Text: In Conversation With… Edward Kelley, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. …