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1661. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49543/psn-pdf
      September 01, 2007 - Medication Reconciliation: Whose Job Is It? September 1, 2007 Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it Case Objectives Appreciate the prevalence and impact of medication discrepancies at times of transition in …

1662. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49584/psn-pdf
      April 01, 2009 - EMR Entry Error: Not So Benign April 1, 2009 Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign The Case A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint of shortness of breath. He was …

1663. Long-term Care and Patient Safety | PSNet
      psnet.ahrq.gov/primer/long-term-care-and-patient-safety
      February 24, 2022 - Long-term Care and Patient Safety Citation Text: Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

1664. Treatment Challenges After Discharge | PSNet
      psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
      January 03, 2017 - SPOTLIGHT CASE Treatment Challenges After Discharge Citation Text: Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar Bib…

1665. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49760/psn-pdf
      May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…

1666. Complaints as Safety Surveillance | PSNet
      psnet.ahrq.gov/web-mm/complaints-safety-surveillance
      May 05, 2021 - Complaints as Safety Surveillance Citation Text: Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

1667. Code Blue—Where To? | PSNet
      psnet.ahrq.gov/web-mm/code-blue-where
      March 30, 2020 - Code Blue—Where To? Citation Text: Adams BD. Code Blue—Where To?. 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…

1668. It's Sarah, Not Stephen! | PSNet
      psnet.ahrq.gov/web-mm/its-sarah-not-stephen
      January 01, 2015 - SPOTLIGHT CASE It's Sarah, Not Stephen! Citation Text: Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

1669. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847934/psn-pdf
      April 26, 2023 - Patient Safety Indicators April 26, 2023 Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/patient-safety-indicators Background Over the past 25 years, policymakers and providers, payers, and purchasers of health care have increasingly focused attention on pati…

1670. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
      May 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer? * * Source and Credits This presentation is based on the May 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Sidney W.A. Dekker, Ph…

1671. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861838/psn-pdf
      January 31, 2024 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling January 31, 2024 https://psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling Summary Adverse events resulting from medications are a common occurrence that often go undetected, unreported, and unaddressed.1 The imp…

1672. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
      November 01, 2005 - senior leadership support Secure commitment for resources for the project during its development Start

1673. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33649/psn-pdf
      May 01, 2007 - And I did start to challenge these doctors' colleagues, who were usually protecting their associates … Then we can start to highlight areas where things are getting better.

1674. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73229/psn-pdf
      May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities May 26, 2021 Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…

1675. Antiseizure Medication Disorder | PSNet
      psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
      April 01, 2006 - SPOTLIGHT CASE Antiseizure Medication Disorder Citation Text: Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX En…

1676. July Syndrome | PSNet
      psnet.ahrq.gov/web-mm/july-syndrome
      July 01, 2011 - various members of the interprofessional team during the transition, and the implementation of staggered start

1677. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33806/psn-pdf
      April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH April 1, 2016 In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics a…

1678. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49732/psn-pdf
      May 01, 2015 - Errors in Sepsis Management May 1, 2015 Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/errors-sepsis-management Case Objectives Define sepsis, severe sepsis, and septic shock. Describe the severe sepsis/septic shock resuscitation bundle. Recognize commonly encou…

1679. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49571/psn-pdf
      October 01, 2008 - Coming Up Short October 1, 2008 Hochberg Z'ev. Coming Up Short. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/coming-short The Case A 12-year-old Hispanic female was seen for a well-child check. The child was delivered 2 months prematurely (likely due to domestic violence) in Puerto Rico. She had an intra…

1680. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33642/psn-pdf
      November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006 In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you become interested…