-
psnet.ahrq.gov/node/41187/psn-pdf
October 16, 2012 - A pharmacist-led information technology intervention for
medication errors (PINCER): a multicentre, cluster
randomised, controlled trial and cost-effectiveness
analysis.
October 16, 2012
Avery A, Rodgers S, Cantrill JA, et al. A pharmacist-led information technology intervention for medication
errors (PINCER): a …
-
psnet.ahrq.gov/node/43539/psn-pdf
March 26, 2015 - Challenges and remediation for Patient Safety Indicators
in the transition to ICD-10-CM.
March 26, 2015
Boyd AD, Yang YM, Li J, et al. Challenges and remediation for Patient Safety Indicators in the transition to
ICD-10-CM. J Am Med Inform Assoc. 2015;22(1):19-28. doi:10.1136/amiajnl-2013-002491.
https://psnet.ahr…
-
psnet.ahrq.gov/node/48139/psn-pdf
July 17, 2019 - 'Poking the skunk': ethical and medico-legal concerns in
research about patients' experiences of medical injury.
July 17, 2019
Moore JS, Mello MM, Bismark M. 'Poking the skunk': Ethical and medico-legal concerns in research about
patients' experiences of medical injury. Bioethics. 2019;33(8):948-957. doi:10.1111/bi…
-
psnet.ahrq.gov/node/48016/psn-pdf
January 01, 2020 - Reducing three infections across cardiac surgery
programs: a multisite cross-unit collaboration.
May 22, 2019
Chang BH, Hsu Y-J, Rosen MA, et al. Reducing Three Infections Across Cardiac Surgery Programs: A
Multisite Cross-Unit Collaboration. Am J Med Qual. 2020;35(1):37-45. doi:10.1177/1062860619845494.
https://p…
-
psnet.ahrq.gov/node/47831/psn-pdf
May 08, 2019 - What US hospitals are currently doing to prevent common
device-associated infections: results from a national
survey.
May 8, 2019
Saint S, Greene MT, Fowler KE, et al. What US hospitals are currently doing to prevent common device-
associated infections: results from a national survey. BMJ Qual Saf. 2019;28(9):741…
-
psnet.ahrq.gov/node/865309/psn-pdf
May 29, 2024 - A Stable Airway? Fatal Airway Occlusion After Inadequate
Post-Tracheostomy Care
May 29, 2024
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-
Tracheostomy Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-i…
-
psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - SPOTLIGHT CASE
"The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety
Citation Text:
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
-
psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - Missed Opportunities for Suicide Risk Assessment
November 27, 2019
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…
-
psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
-
psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx
Spotlight
Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See…
-
psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - Too Many Cooks in the Kitchen
August 26, 2020
Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for
Continuing Medical Education (ACCME), the Un…
-
psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Total Parenteral Nutrition, Multifarious Errors
April 1, 2013
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
Case Objectives
Define parenteral nutrition (PN).
Describe the PN-use process.
Identify …
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case July 2004
Preventing Inappropriate Use of Novel Therapeutic Agents
Source and Credits
This presentation is based on the July 2004 AHRQ WebM&M Spotlight Case in Critical Care Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the W…
-
psnet.ahrq.gov/node/33598/psn-pdf
June 15, 2024 - Falls
June 15, 2024
Falls. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/falls
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 2024.
Background
Falls are a common …
-
psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
September 15, 2024 - Disruptive and Unprofessional Behavior
Citation Text:
Disruptive and Unprofessional Behavior. 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…
-
psnet.ahrq.gov/primer/patient-engagement-and-safety
August 30, 2023 - Patient Engagement and Safety
Citation Text:
Patient Engagement and Safety. 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 Pu…
-
psnet.ahrq.gov/node/33568/psn-pdf
June 15, 2024 - Root Cause Analysis
June 15, 2024
Root Cause Analysis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/root-cause-analysis
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…
-
psnet.ahrq.gov/issue/hospital-discharge-review-high-risk-care-transition-highlights-reengineered-discharge-process
December 16, 2014 - Study
The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process.
Citation Text:
Greenwald JL, Denham CR, Jack BW. The Hospital Discharge. J Patient Saf. 2008;3(2). doi:10.1097/01.jps.0000236916.94696.12.
Copy Citation
For…
-
psnet.ahrq.gov/issue/brave-men-and-emotional-women-theory-guided-literature-review-gender-bias-health-care-and
June 09, 2021 - psnet
-
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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…