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psnet.ahrq.gov/node/35863/psn-pdf
March 18, 2010 - Healthcare industry representatives: maximizing benefits
and reducing risks.
March 18, 2010
PA PSRS Patient Saf Advis 2006 Mar;3(1):13-19.
https://psnet.ahrq.gov/issue/healthcare-industry-representatives-maximizing-benefits-and-reducing-risks
This article addresses strategies for minimizing patient safety risks re…
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Approach to Improving Safety
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Approach to Improving Safety (1)
• This case represents a classic … Each layer of cheese
represents an independent layer of defense against error as long as
the holes
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - In the Swiss Cheese Model, each “slice” of “cheese”
represents a measure taken to enhance patient safety … Each “moment” represents a point in medication use when actions by the patient or caregiver
can reduce
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - In the Swiss Cheese Model, each “slice” of “cheese” represents a measure taken to enhance patient safety … Each “moment” represents a point in medication use when actions by the patient or caregiver can reduce
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psnet.ahrq.gov/issue/raising-index-suspicion-red-flags-represent-credible-threats-patient-safety
February 13, 2019 - Newspaper/Magazine Article
Raising the index of suspicion: red flags that represent credible threats to patient safety.
Citation Text:
Raising the index of suspicion: red flags that represent credible threats to patient safety. ISMP Medication Safety Alert! Acute Care Edition. July 26, 2…
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psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - side effects of intravenous gentamicin therapy, the erroneous intravenous administration
of this drug represents
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psnet.ahrq.gov/node/843736/psn-pdf
February 01, 2023 - Approach to Improving Patient Safety
While the patient in this case ultimately had a good outcome, it represents
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psnet.ahrq.gov/node/33848/psn-pdf
December 01, 2017 - attending then gravely addressed
the assembled surgical attendings and residents:
I think that this case represents
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psnet.ahrq.gov/node/49460/psn-pdf
September 01, 2004 - The Commentary
This case represents a common situation in which a medical student, having noticed an
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psnet.ahrq.gov/issue/prospective-memory-icu-effect-visual-cues-task-execution-representative-simulation
April 24, 2018 - Study
Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation.
Citation Text:
Grundgeiger T, Sanderson PM, Orihuela B, et al. Prospective memory in the ICU: the effect of visual cues on task execution in a representative simulation. Ergo…
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psnet.ahrq.gov/node/41580/psn-pdf
June 10, 2018 - Raising the index of suspicion: red flags that represent
credible threats to patient safety.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. July 26, 2012;17:1-3.
https://psnet.ahrq.gov/issue/raising-index-suspicion-red-flags-represent-credible-threats-patient-safety
This newsletter article highlig…
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - 2 out of 2 blood cultures positive with the same pathogen, even one that is commonly a contaminant, represents
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psnet.ahrq.gov/issue/using-pediatric-trigger-tool-estimate-total-harm-burden-hospital-acquired-conditions
July 03, 2016 - Study
Using a pediatric trigger tool to estimate total harm burden hospital-acquired conditions represent.
Citation Text:
Stockwell DC, Landrigan CP, Schuster MA, et al. Using a Pediatric Trigger Tool to Estimate Total Harm Burden Hospital-acquired Conditions Represent. Pediatr Qual Saf.…
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psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - The Commentary
The case presented represents a near miss.
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psnet.ahrq.gov/node/49442/psn-pdf
May 01, 2004 - The Commentary
This case represents an unfortunate failure to identify tuberculosis (TB) in a young
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psnet.ahrq.gov/node/33850/psn-pdf
January 01, 2018 - The OpenNotes initiative—which allows patients
to read their clinicians' notes—represents another real
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.149_slideshow.ppt
May 01, 2007 - Phenytoin Levels
90% bound to plasma proteins, primarily albumin
Therapeutic range of 10-20 mcg/mL represents
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psnet.ahrq.gov/node/33868/psn-pdf
October 01, 2018 - However, unsafe medication use represents a major public health concern, especially for older adults
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psnet.ahrq.gov/node/49510/psn-pdf
May 01, 2006 - As seen in this case, the inadvertent mix-up of unlabeled medication cups represents an understandable
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psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - Lest readers think this error represents a tragic “fluke,” another breast cancer patient received an