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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - Commander's Aviation Training and Standardization Program. August 2016. TC 3-04.11 12.
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psnet.ahrq.gov/node/33723/psn-pdf
December 01, 2011 - higher in
the U.S. (23) than in some other countries.(24) While in many other areas of patient safety standardization
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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - SPOTLIGHT CASE
Thin Air
Citation Text:
Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Spotlight
Missed Opportunities for Suicide
Risk Assessment
Source and Credits
• This presentation is based on the November 2019 AHRQ WebM&M
Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Glen Xiong, MD & Debra Kahn, MD
○ Editors in Chief, AHRQ We…
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - Who Nose Where the Airway Is?
Citation Text:
Lee CR. Who Nose Where the Airway Is?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/discharging-our-responsibility
January 16, 2019 - Discharging Our Responsibility
Citation Text:
Fonarow GC. Discharging Our Responsibility. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…
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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - Root Cause Analysis Gone Wrong
May 1, 2018
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
The Case
A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney
transplant. A suitabl…
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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - Medication Mix-Up Leads to Patient Death
November 30, 2023
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
The Case
An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - Undetected Foreign Object
Citation Text:
Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/periodic-issue/periodic-issue-469
December 31, 2024 - January 8, 2025 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…
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Root Cause Analysis Gone Wrong
Citation Text:
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
May 01, 2016 - Practice standards for ECG monitoring in hospital settings: executive summary and guide for implementation
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psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
March 01, 2009 - So developing standards and verification tools for prescription labels or prescription labeling systems
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psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
March 01, 2019 - many of these are business deals rather than clinical deals, part of the business arrangement is to do standardization … How do you reconcile that the practice standards in the community may be slightly different than those
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - We haven't been more rigorous about
standardization.
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psnet.ahrq.gov/issue/it-left-eye-right
September 06, 2023 - Study
"It is the left eye, right?"
Citation Text:
Pikkel D, Sharabi-Nov A, Pikkel J. "It is the left eye, right?". Risk Manag Healthc Policy. 2014;7:77-80. doi:10.2147/RMHP.S60728.
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psnet.ahrq.gov/issue/duplication-surgical-site-marking
November 18, 2016 - Commentary
Duplication of surgical site marking.
Citation Text:
Davis JS, Karmacharya J, Schulman C. Duplication of surgical site marking. J Patient Saf. 2012;8(4):151-2. doi:10.1097/PTS.0b013e3182699a01.
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psnet.ahrq.gov/issue/cdc-grand-rounds-preventing-unsafe-injection-practices-us-health-care-system
February 27, 2019 - Government Resource
CDC Grand Rounds: preventing unsafe injection practices in the U.S. health-care system.
Citation Text:
Prevention C for DC and. CDC grand rounds: preventing unsafe injection practices in the U.S. health-care system. MMWR Morb Mortal Wkly Rep. 2013;62(21):423-5.
Cop…