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psnet.ahrq.gov/issue/innovation-patient-safety-new-task-design-reducing-patient-falls
January 04, 2010 - Study
Innovation in patient safety: a new task design in reducing patient falls.
Citation Text:
Tzeng H-M, Yin C-Y. Innovation in patient safety: a new task design in reducing patient falls. J Nurs Care Qual. 2008;23(1):34-42. doi:10.1097/01.NCQ.0000303803.07457.e5.
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psnet.ahrq.gov/web-mm/outbreak
January 29, 2015 - Outbreak
Citation Text:
Rothman R, Stapleton S. Outbreak. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/841567/psn-pdf
December 14, 2022 - Measuring Patient Safety
December 14, 2022
Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/measuring-patient-safety
Following the landmark report To Err is Human: Building a Safer Health System, developed by the Institute
of Medicine in 1999, pa…
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psnet.ahrq.gov/web-mm/walking-patient-missing-drain
April 01, 2006 - Walking Patient, Missing Drain
Citation Text:
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
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psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable
Citation Text:
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. 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/miscommunication-or-leads-anticoagulation-mishap
May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap
Citation Text:
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Forma…
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psnet.ahrq.gov/node/837658/psn-pdf
July 08, 2022 - Preventable Transfer to the Hospital
July 8, 2022
Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/preventable-transfer-hospital
The Case
A 78-year-old veteran with dementia-associated aggressive behavior and multiple comorbidities had…
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psnet.ahrq.gov/node/49536/psn-pdf
May 01, 2007 - On the Other Hand
May 1, 2007
Henneman EA. On the Other Hand. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/other-hand
The Case
A young woman with Takayasu's arteritis presented to the hospital with severe abdominal pain. The patient
had been diagnosed with Takayasu's a decade earlier. The disease results…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case July 2007
Resuscitation Errors:
A Shocking Problem
Source and Credits
This presentation is based on the July 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Benjamin Abella, MD, MPhil, …
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - Methicillin-Resistant Staphylococcus aureus
April 1, 2008
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
Perspective
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Infused, Not Ingested
November 1, 2005
Foley M. Infused, Not Ingested. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/infused-not-ingested
The Case
A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering
contrast, an unfamiliar task for this particular nurse. Rathe…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
July 01, 2012 - Spotlight Case July 2008
Spotlight Case
Not-So-Therapeutic Tap
*
*
Source and Credits
This presentation is based on the July 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeffrey H. Barsuk, MD, MS; Northwestern University Feinberg Scho…
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psnet.ahrq.gov/node/33700/psn-pdf
October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD
October 1, 2010
In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
Editor's note: Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and He…
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psnet.ahrq.gov/node/33682/psn-pdf
April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH
April 1, 2009
In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
Editor's note: Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent
s…
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psnet.ahrq.gov/node/49797/psn-pdf
June 01, 2017 - Diagnostic Overshadowing Dangers
June 1, 2017
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
The Case
A 72-year-old woman with history of opioid abuse was sent to the emergency department (ED) from a
methadone clinic because she a…
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psnet.ahrq.gov/node/48145/psn-pdf
July 17, 2019 - Mental mayhem: the peril of multitasking in medicine.
July 17, 2019
Joseph R; Harry E.
https://psnet.ahrq.gov/issue/mental-mayhem-peril-multitasking-medicine
Multitasking can negatively affect cognitive load and diminish safety. This magazine article reports on how
multitasking can contribute to surgeon fatigue, b…
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psnet.ahrq.gov/node/37286/psn-pdf
December 23, 2011 - Different roles, same goal: risk and quality management
partnering for patient safety. By the ASHRM Monographs
Task Force.
December 23, 2011
Bokar V, Perry DG. Different Roles, Same Goal: Risk And Quality Management Partnering For Patient
Safety. By The Ashrm Monographs Task Force.; 2007:17-23, 25. doi:10.1002/jhr…
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psnet.ahrq.gov/node/41094/psn-pdf
January 25, 2012 - Adverse event reporting tool to standardize the reporting
and tracking of adverse events during procedural
sedation: a consensus document from the World SIVA
International Sedation Task Force.
January 25, 2012
Mason KP, Mason KP, Green SM, et al. Adverse event reporting tool to standardize the reporting and
track…
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psnet.ahrq.gov/node/38492/psn-pdf
September 12, 2016 - Practice advisory on anesthetic care for magnetic
resonance imaging: a report by the American Society of
Anesthesiologists Task Force on Anesthetic Care for
Magnetic Resonance Imaging.
September 12, 2016
Practice advisory on anesthetic care for magnetic resonance imaging: an updated report by the american
society…