-
psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - Evaluating the short message service alerting system for critical value notification via PDA telephones
-
psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - SPOTLIGHT CASE
Physical Diagnosis: A Lost Art?
Citation Text:
Thompson GR, Verghese A. Physical Diagnosis: A Lost Art?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Schola…
-
psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - Pregnant With Danger
Citation Text:
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
-
psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - patients may have an IUC inserted sometime during their hospital stay, with most only used for the short-term … Because the urethral length is quite short (3–4 cm), female catheter placement is generally simple, straightforward
-
psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - surgical complications.( 1,2,6 ) While we appreciate these advantages of RAS, most of these benefits are short … Although robotic-assisted surgery shows some short-term benefits surrounding the direct perioperative
-
psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - best practices” may be limited by the local availability of inpatient psychiatric beds, which are in short … Short shrift for the sane?
-
psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - However, the short interval between LMWH and spinal needle placement in this case is not in line with … Although this patient did not experience an adverse event attributable to the short interval, placement
-
psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - Bridging anticoagulation refers to the use of a short-acting anticoagulant during periods when a longer … Peripheral IV in Too Long
September 1, 2012
Effect of day of the week on short
-
psnet.ahrq.gov/web-mm/what-was-those-platelets
August 28, 2024 - What Was in Those Platelets?
Citation Text:
Yomtovian R. What Was in Those Platelets? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
-
psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - It is also possible that the nurse was rushing due to short staffing in the NICU, which is a systems
-
psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - In the short term, emergent complications include tube decannulation, tube obstruction, and hemorrhage
-
psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - it is reasonable to try Trendelenburg positioning and direct pressure at the site of durotomy for a short … However, an analysis of published reports suggested that antibiotics do not decrease the short- or long-term … suspected lumbar durotomy is exhibiting symptoms, it is reasonable to try Trendelenburg positioning for a short
-
psnet.ahrq.gov/node/33585/psn-pdf
March 15, 2025 - Radiation Safety
March 15, 2025
Radiation Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/radiation-safety
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 2025…
-
psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
November 01, 2012 - did on the cognitive portion, you had to appear before the examiners and examine a long case and a short … Transport
July 31, 2024
WebM&M Cases
Coming Up Short
-
psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - For example, studies using observers have generally employed relatively short observation periods ( 2,7 … dispensers, it is possible that patients and family members pushed the dispenser multiple times in a short … thus it requires a great effort in training data collectors; c) time intensive for observers; d) and short
-
psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - Within a very short period, productivity in that plant was great. Quality was super. … behavior, called first-order problem solving, seems successful because patient care continues in the short
-
psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
April 24, 2024 - The Think Tank’s focus was on short-term actions that could be taken at an institutional level to address … In the short term, how are healthcare organizations using agency or travel nurses to address the shortages
-
psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - The Think Tank’s focus was on short-term actions that could be taken at an institutional level to address … In the short term, how are healthcare organizations using agency or travel nurses to address the shortages
-
psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - plan. 21
Several added factors that could have led to diagnostic error in this case include:
Short … February 1, 2010
WebM&M Cases
Coming Up Short
-
psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - on additional training to secure continued supervision.( 16-18 ) Patient safety may benefit in the short