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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854258/psn-pdf
    October 04, 2023 - A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings. October 4, 2023 Phillips KK, Mecca MC, Baim?Lance AM, et al. A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39249/psn-pdf
    September 30, 2015 - Patient participation: current knowledge and applicability to patient safety. September 30, 2015 Longtin Y, Sax H, Leape L, et al. Patient participation: current knowledge and applicability to patient safety. Mayo Clin Proc. 2010;85(1):53-62. doi:10.4065/mcp.2009.0248. https://psnet.ahrq.gov/issue/patient-particip…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837797/psn-pdf
    August 10, 2022 - Toward constructive change after making a medical error: recovery from situations of error theory as a psychosocial model for clinician recovery. August 10, 2022 Harrison R, Johnson J, Mcmullan RD, et al. Toward constructive change after making a medical error: recovery from situations of error theory as a psychos…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50792/psn-pdf
    January 15, 2020 - Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center January 15, 2020 Businger AC, Fuller TE, Schnipper JL, et al. Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medi…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36315/psn-pdf
    July 10, 2008 - Wrong-side/wrong-site, wrong-procedure, and wrong- patient adverse events: are they preventable? July 10, 2008 Seiden SC, Barach P. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: Are they preventable? Arch Surg. 2006;141(9):931-9. https://psnet.ahrq.gov/issue/wrong-sidewrong-site-wrong-p…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45648/psn-pdf
    February 01, 2017 - Findings of a naloxone database and its utilization to improve safety and education in a tertiary care medical center. February 1, 2017 Rosenfeld DM, Betcher JA, Shah RA, et al. Findings of a Naloxone Database and its Utilization to Improve Safety and Education in a Tertiary Care Medical Center. Pain Pract. 2016;1…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866159/psn-pdf
    June 19, 2024 - Stakeholder perspectives on contributors to delayed and inaccurate diagnosis of cardiovascular disease and their implications for digital health technologies: a UK-based qualitative study. June 19, 2024 Abdullayev K, Gorvett O, Sochiera A, et al. Stakeholder perspectives on contributors to delayed and inaccurate …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866900/psn-pdf
    October 09, 2024 - Defects in value associated with hospital-acquired conditions: how improving quality could save U.S. healthcare $50 billion. October 9, 2024 Padula WV, Pronovost PJ. Defects in value associated with hospital-acquired conditions: how improving quality could save U.S. healthcare $50 billion. J Patient Saf. 2024;20(7…
  9. psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Intraoperative Awareness during Rhinoplasty 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Christian Bohringer MBBS and Jaijeet Toor MD AHRQ WebM&M Edit…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49537/psn-pdf
    June 01, 2007 - Beeline to Spine June 1, 2007 Smetana GW. Beeline to Spine. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/beeline-spine Case Objectives Understand the elements of preoperative medical evaluation. Appreciate the limited role for preoperative laboratory testing. Appreciate the importance of communication a…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49849/psn-pdf
    January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep January 1, 2019 Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep Case Objectives List the patient safety events that are unique to in…
  12. psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
    March 27, 2024 - Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …
  13. psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
    February 10, 2021 - SPOTLIGHT CASE A Fatal Twist in Pseudohyperkalemia Citation Text: Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …
  14. psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
    March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy Citation Text: Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
  15. psnet.ahrq.gov/web-mm/elopement
    July 14, 2010 - SPOTLIGHT CASE Elopement Citation Text: Gerardi D. Elopement. 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 PubMe…
  16. psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
    May 01, 2008 - SPOTLIGHT CASE A Painful Medication Reconciliation Mishap Citation Text: Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google S…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49675/psn-pdf
    February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to Significant Complications February 1, 2013 Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865540/psn-pdf
    April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration April 11, 2024 Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration The Case An 82-year-old woman presented to the Emergency Department (ED) for …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863308/psn-pdf
    February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy February 28, 2024 Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy The Case A…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49388/psn-pdf
    February 01, 2003 - Unexplained Apnea Under Anesthesia February 1, 2003 Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia Case Objectives Clinical Objectives List the causes of prolonged apnea in the operating room Describe the steps in management …

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