-
psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
-
psnet.ahrq.gov/node/49540/psn-pdf
August 21, 2007 - Resuscitation Errors: A Shocking Problem
August 21, 2007
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
Case Objectives
Appreciate that delays in defibrillation can have significant negative effects on sur…
-
psnet.ahrq.gov/node/33678/psn-pdf
January 01, 2009 - In Conversation with…Thomas H. Gallagher, MD
January 1, 2009
In Conversation with…Thomas H. Gallagher, MD. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md
Editor's note: Thomas H. Gallagher, MD, is Associate Professor in the Department of Medicine and the
Departme…
-
psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
…
-
psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - Pre-analytical pitfalls: Missing and mislabeled specimens
February 26, 2020
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
The Case
Case #1:
A 56-year-old man was admitted to…
-
psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
-
psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Dangerous Shift
November 1, 2008
Patterson ES. Dangerous Shift. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dangerous-shift
Case Objectives
Review the evidence base on erroneous actions related to shift changes.
Understand the limits of standardizing handoffs in preventing errors at shift change.
Expla…
-
psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - Antonio course has also led to development of QI curriculum for medical and nursing students, and for residents
-
psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - Moreover, since 2012, emergency medicine accreditation requires that residents achieve competency in
-
psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
July 01, 2008 - October 21, 2011
The Pursuing Excellence Collaborative: engaging first-year residents
-
psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - notified after "trigger" events.( 16 ) A list of 13 triggers that should lead to communication between residents
-
psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
Also Read an Essay
Also Read an Essay
Citation Text:
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.In Conversation with...James P. Bagian, MD. PSNet [internet]. Rockville (MD): Ag…
-
psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx
Spotlight
The Dose Makes the Poison: Medication Error During
Procedural Sedation in the Pediatric Emergency
Department
Source and Credits
• This presentation is based on the April 2023 AH…
-
psnet.ahrq.gov/perspective/conversation-jeffrey-starke-md
September 11, 2023 - Residents now have duty hour restrictions and more of an emphasis on admitting that you're sick, admitting
-
psnet.ahrq.gov/node/33750/psn-pdf
May 01, 2013 - we fail to deliver good
care, despite my best intentions, despite the best of intentions of nurses, residents
-
psnet.ahrq.gov/node/33610/psn-pdf
April 01, 2005 - Introducing the New AHRQ WebM&M and AHRQ Patient
Safety Network (PSNet)
April 1, 2005
Wachter R. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet). PSNet
[internet]. 2005.
https://psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
Editorial
Five year…
-
psnet.ahrq.gov/node/33836/psn-pdf
June 01, 2017 - The Weekend Effect in Cardiology: Is It Real? If So, Can It
Be Fixed?
June 1, 2017
Martin VK, Mirnateghi N, Khoshchehreh M. The Weekend Effect in Cardiology: Is It Real? If So, Can It Be
Fixed? . PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
Per…
-
psnet.ahrq.gov/node/49752/psn-pdf
January 01, 2016 - Inadvertent Use of More Potent Acid Leads to Burn
January 1, 2016
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
The Case
A 31-year-old woman came to the clinic for a routine well-woman evaluation. She…
-
psnet.ahrq.gov/primer/disclosure-errors
September 15, 2024 - Disclosure of Errors
Citation Text:
Disclosure of Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
-
psnet.ahrq.gov/primer/rapid-response-systems
July 18, 2024 - Rapid Response Systems
Citation Text:
Rapid Response Systems. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…