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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852699/psn-pdf
    August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety August 30, 2023 Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety The COVID-19 pandemic necessitated a shift in operations …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49562/psn-pdf
    May 01, 2008 - The Inside of a Time Out May 1, 2008 Feldman DL. The Inside of a Time Out. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/inside-time-out The Case A 65-year-old man was scheduled for an elective endovascular repair of an abdominal aortic aneurysm. The patient had an allergy to "IV contrast dye" that was no…
  3. psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
    November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012  View more articles from the same authors. Citation Text: Joseph A, Malone EB. The Physical Environment: An Often Unc…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50756/psn-pdf
    December 18, 2019 - A Mistaken Dose of Naloxone? December 18, 2019 Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone The Case A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up appointment. He h…
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
    June 01, 2015 - PowerPoint Presentation Spotlight Anchoring Bias With Critical Implications 1 This presentation is based on the June 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Edward Etchells, MD, MSc, Division of General Internal Medicine, Centre for Q…
  6. psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
    February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness Suzanne Beyea, RN, PhD | February 1, 2014  Also Read the Conversations In Conversation With… Enrico Coiera, MB, BS, PhD In Conversation With… Richard Kronick, PhD View more …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33761/psn-pdf
    February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness February 1, 2014 Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
    December 01, 2015 - PowerPoint Presentation Spotlight Harm From Alarm Fatigue This presentation is based on the December 2015 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50393/psn-pdf
    September 01, 2019 - Patient Safety and the Evolution of WebM&M and PSNet September 1, 2019 Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet Perspective Progress in any field requires scholarship and dissem…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33749/psn-pdf
    April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety? April 1, 2013 Fletcher KE, Reed DA. Are Residency Duty Hour Rules Improving Patient Safety? PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety Perspective Introduction The Accreditation Council f…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49867/psn-pdf
    July 02, 2019 - Diuretics and Electrolyte Abnormalities July 2, 2019 Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities Case Objectives Recognize that thiazide diuretics can lead to serious adverse events. State how commonly used t…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49656/psn-pdf
    June 01, 2012 - Comanagement: Who's in Charge? June 1, 2012 Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/comanagement-whos-charge The Case A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left hip fracture to the orthopedic surg…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33579/psn-pdf
    September 15, 2024 - Systems Approach September 15, 2024 Systems Approach. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/systems-approach 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 …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49866/psn-pdf
    June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the Operating Room June 1, 2019 Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room The Case A 43-year-old woman was admi…
  15. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
    November 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfusion Overload 1 2 Source and Credits This presentation is based on the November 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …
  16. psnet.ahrq.gov/perspective/patient-and-family-roles-safety
    June 14, 2023 - reviewed by the guide’s authors shows that including patients and families during care transitions reduces
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46439/psn-pdf
    August 20, 2018 - Hospital-readmission risk--isolating hospital effects from patient effects. August 20, 2018 Krumholz HM, Wang K, Lin Z, et al. Hospital-Readmission Risk - Isolating Hospital Effects from Patient Effects. N Engl J Med. 2017;377(11):1055-1064. doi:10.1056/NEJMsa1702321. https://psnet.ahrq.gov/issue/hospital-readmiss…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44974/psn-pdf
    April 12, 2019 - Medicare letters to curb overprescribing of controlled substances had no detectable effect on providers. April 12, 2019 Sacarny A, Yokum D, Finkelstein A, et al. Medicare Letters To Curb Overprescribing Of Controlled Substances Had No Detectable Effect On Providers. Health Aff (Millwood). 2016;35(3):471-9. doi:10.…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46807/psn-pdf
    July 02, 2019 - Communication failure: analysis of prescribers' use of an internal free-text field on electronic prescriptions. July 2, 2019 Ai A, Wong A, Amato MG, et al. Communication failure: analysis of prescribers’ use of an internal free-text field on electronic prescriptions. J Am Med Inform Assoc. 2018;25(6):709-714. doi:1…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46910/psn-pdf
    January 23, 2019 - Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for improvement, not blame. January 23, 2019 Armstrong N, Brewster L, Tarrant C, et al. Taking the heat or taking the temperature? A qualitative study of a large-scale exercise in seeking to measure for i…

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