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  1. Psn-Pdf (pdf file)

    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 …
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. 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…
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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-…
  10. 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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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 …
  13. 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…
  14. Psn-Pdf (pdf file)

    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 …
  15. 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…
  16. 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…
  17. Psn-Pdf (pdf file)

    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…
  18. 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…
  19. psnet.ahrq.gov/issue/brave-men-and-emotional-women-theory-guided-literature-review-gender-bias-health-care-and
    June 09, 2021 - psnet
  20. 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 …

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