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psnet.ahrq.gov/periodic-issue/periodic-issue-439
May 29, 2024 - May 8, 2024 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, an…
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psnet.ahrq.gov/node/49446/psn-pdf
August 30, 2021 - Too Tight Control
May 1, 2004
Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/too-tight-control
Case Objectives
Appreciate the advantages and potential complications of intensive insulin therapy in the hospitalized
patient
List hospital-based safeguards available to…
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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error
Citation Text:
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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…
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Are You Mrs. A? An Issue of Identification Over Telephone
Citation Text:
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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…
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psnet.ahrq.gov/web-mm/real-heartache
October 01, 2018 - A Real Heartache
Citation Text:
Polevoi SK. A Real Heartache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/33758/psn-pdf
December 01, 2013 - In Conversation With… Hardeep Singh, MD, MPH
December 1, 2013
In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
Editor's note: Hardeep Singh, MD, MPH, is Chief of the Health Policy, Quality and Informatics Program at
the Hous…
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - Discontinued Medications: Are They Really Discontinued?
Citation Text:
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfer Troubles
1
2
Source and Credits
This presentation is based on the June 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case of Mistaken Intubation
June 1, 2016
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
Case Objectives
Appreciate that most older adults and many younger chronically ill patients have discussed or
documented their preferences for l…
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - Crossed Coverage
Citation Text:
Kayser SR. Crossed Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - SPOTLIGHT CASE
Falling Through the Crack (in the Bedrails)
Citation Text:
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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F…
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psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
August 01, 2014 - We try to imbue that in our residents, and they are teaching us how to do that well.
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psnet.ahrq.gov/issue/preventing-workplace-violence
July 25, 2023 - Clinician Burnout: The Ohio State University
November 13, 2019
Keeping Nursing Home Residents
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psnet.ahrq.gov/issue/use-bar-code-technology-medication-administration
January 23, 2019 - October 5, 2005
Bipartisan Consensus: The Public Wants Well-Rested Medical Residents
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psnet.ahrq.gov/issue/how-human-factors-lead-medical-device-adverse-events
February 10, 2021 - October 5, 2005
Bipartisan Consensus: The Public Wants Well-Rested Medical Residents
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psnet.ahrq.gov/node/33761/psn-pdf
February 01, 2014 - Studying surgical residents in a simulated environment, Feuerbacher and colleagues (11) found that in
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
August 01, 2012 - at least one delay in reviewing test results over the past 2 months
In a survey of internal medicine residents
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - A nursing care center goal includes preventing falls in patients and nursing home residents by identifying
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psnet.ahrq.gov/periodic-issue/periodic-issue-405
August 30, 2023 - Researchers surveyed a sample of 687 residents and fellows from over 30 specialties about handoff training
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - A randomized controlled trial of an educational intervention with internal medicine residents.