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9941. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy | PSNet
      psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
      March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy Citation Text: Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…

9942. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33830/psn-pdf
      March 22, 2016 - Measuring and Responding to Deaths From Medical Errors March 22, 2016 Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors Annual Perspective 2016 The Prevalence of Deaths Due to Preventable Adve…

9943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33647/psn-pdf
      March 01, 2007 - The Role of the Patient in Improving Patient Safety March 1, 2007 Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/role-patient-improving-patient-safety Perspective Patients have three roles in improving patient safety: helping to ensure thei…

9944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33571/psn-pdf
      March 15, 2025 - Reporting Patient Safety Events March 15, 2025 Reporting Patient Safety Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/reporting-patient-safety-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in th…

9945. Handoffs | PSNet
      psnet.ahrq.gov/primer/handoffs
      October 18, 2023 - Handoffs Citation Text: Handoffs and Signouts. 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 PubMedId RIS Download…

9946. The Role of Bar Coding and Smart Pumps in Safety | PSNet
      psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
      September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN | September 1, 2008  Also Read a Conversation View more articles from the same authors. Citation Text: Rothschild JM, Keohane C. The Role of Bar Coding and Sm…

9947. Aviation Safety Methods: Quickly Adopted but Questions Remain | PSNet
      psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
      January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions Remain Eric J. Thomas, MD, MPH | January 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. P…

9948. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60241/psn-pdf
      February 24, 2022 - Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes February 24, 2022 Bakerjian D. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-…

9949. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49800/psn-pdf
      July 01, 2017 - The Hidden Harms of Hand Sanitizer July 1, 2017 Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer The Case A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital for community-acquired pn…

9950. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836812/psn-pdf
      March 30, 2022 - Strategies and Approaches for Investigating Patient Safety Events March 30, 2022 Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events Background This primer provides a broad …

9951. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33871/psn-pdf
      December 22, 2018 - Maternal Safety December 22, 2018 Lyndon A. Maternal Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/maternal-safety Annual Perspective 2018 The Context of Maternal Safety Childbirth-related maternal health outcomes have been worsening for some time in the United States. After a dramatic reduc…

9952. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841306/psn-pdf
      December 14, 2022 - Resilient Healthcare and the Safety-I and Safety-II Frameworks December 14, 2022 Deutsch ES, Van CM, Mossburg SE. Resilient Healthcare and the Safety-I and Safety-II Frameworks. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks Resilient healthca…

9953. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
      October 01, 2003 - Spotlight Case [MONTH] 2003 Spotlight Case October 2003 Hemivulvectomy: Wrong Side Removed Source and Credits This presentation is based on the Oct. 2003 AHRQ WebM&M Spotlight Case in OB/GYN See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Charles Vin…

9954. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33612/psn-pdf
      May 01, 2005 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience May 1, 2005 Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/organizat…

9955. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49499/psn-pdf
      December 02, 2020 - An Outpatient 'Zebra' January 1, 2006 Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/outpatient-zebra The Case A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness. His past medical history included lumbar disc diseas…

9956. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.191_slideshow.ppt
      January 01, 2009 - Spotlight Case July 2008 Spotlight Case January 2009 To Transfer or Not to Transfer Source and Credits This presentation is based on the January 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jesse M. Pines, MD, MBA, MSCE University o…

9957. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
      May 01, 2011 - Spotlight Case July 2008 Spotlight Case Duty to Disclose Someone Else’s Error * * Source and Credits This presentation is based on the May 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Thomas H. Gallagher, MD University of Washington …

9958. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
      December 01, 2009 - Spotlight Case [MONTH] 2003 Spotlight Case Standard Deviations Source and Credits This presentation is based on the December 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James E. Sabin, MD Harvard Medical School; Harvard Pilgrim Heal…

9959. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
      April 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Bad Writing, Wrong Medication * * Source and Credits This presentation is based on the April 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Beth Devine, PharmD, MBA, PhD University of Washingto…

9960. Pharmacist's Role in Medication Safety | PSNet
      psnet.ahrq.gov/primer/pharmacists-role-medication-safety
      March 14, 2018 - Pharmacist's Role in Medication Safety Citation Text: The Pharmacist's Role in Medication 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…