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psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
April 24, 2018 - a suitable alternative to routine axillary dissection in multi-institutional practice when optimal technique
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psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
September 22, 2010 - that rates of catheter-related bloodstream infection can be decreased with proper catheter insertion technique
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psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/node/33795/psn-pdf
November 01, 2015 - Introducing the Redesigned AHRQ Patient Safety Network
November 1, 2015
Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
Editorial
It's hard to believe that it has been 15 years since th…
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/node/49816/psn-pdf
January 01, 2018 - A Painful Medication Reconciliation Mishap
January 1, 2018
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
Case Objectives
Recognize that substance use disorders are common in patients with acute pain.
Understand th…
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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Lost in Transition
February 1, 2006
Beach C. Lost in Transition. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/lost-transition
Case Objectives
Provide an overview of transitions in continuously operating industries
Review cognitive error
Describe the complex dynamics of transitions in emergency care
Pro…
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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…
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psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
October 01, 2013 - Moreover, this information will help the radiologist optimize the CT technique, reducing the risk of
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psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - Moreover, this information will help the radiologist optimize the CT technique, reducing the risk of
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - rates. 5 The etiology of the stricture and the experience of the proceduralist often determine which technique
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - J R Soc Med . 2003 May;96(5):219-22. [ Free full text ]
The SHARE Approach—Using the teach-Back Technique
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - This technique allows teams to examine patterns across multiple events within a category (such as medication … Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - This technique allows teams to examine patterns across multiple events within a category (such as medication … Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Among those were incorrect drug or dose administered, hypovolemia, and switch to a contraindicated technique
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psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - debriding an NSTI, but the key skills for
successful management of NSTIs involve surgical judgment, not technique
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psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
September 01, 2017 - While the latter technique certainly has advantages for facilitating handoffs, it might also result in
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psnet.ahrq.gov/node/61078/psn-pdf
October 28, 2020 - Additionally, insulin pump infusion site leakage occurred several times, possibly due to
improper insertion technique
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - with his feeling that his worries might be unfounded (maybe this procedure doesn’t require aseptic technique
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psnet.ahrq.gov/web-mm/code-blue-where
March 30, 2020 - Yet the location of this arrest—outside the main hospital—doubtless led to the poor technique, inadequately