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  1. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis | PSNet

    psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
    January 13, 2010 - Saf . 2022;18(6):e999-e1003. [ Free full text ] Advancing safety with closed-loop communication of test

  2. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. | PSNet

    psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
    September 25, 2019 - with this lens, then, that the team appropriately recognizes the syndrome and sends the confirmatory test

  3. In Conversation With… Kaveh Shojania, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
    February 26, 2025 - My early thoughts were that the role of research would be to test some of these putative interventions

  4. Anchoring Bias With Critical Implications | PSNet

    psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
    June 15, 2022 - SPOTLIGHT CASE Anchoring Bias With Critical Implications Citation Text: Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google…

  5. AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety | PSNet

    psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
    August 31, 2020 - created a digital tool to centralize care protocols for emergency physicians. 40 The need to rigorously test

  6. An Inadvertent Bolus of Norepinephrine. | PSNet

    psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
    December 04, 2016 - December 4, 2016 The need for closed-loop systems for management of abnormal test results … July 2, 2019 Understanding test results follow-up in the ambulatory setting: analysis

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73106/psn-pdf
    April 01, 2021 - Strategies and Approaches for Tracking Improvements in Patient Safety April 1, 2021 Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety Background An essential aspect …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50844/psn-pdf
    January 29, 2020 - Improving Patient Safety and Team Communication through Daily Huddles January 29, 2020 Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles Background Communicat…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33595/psn-pdf
    December 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety December 15, 2024 Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that th…

  10. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
    May 01, 2009 - Spotlight Case July 2008 Spotlight Case Delirium or Dementia? Source and Credits This presentation is based on the May 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James L. Rudolph, MD, SM Editor, AHRQ WebM&M: Robert Wachter, MD Sp…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49412/psn-pdf
    September 01, 2003 - Shake Well September 1, 2003 Flynn EA. Shake Well. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/shake-well The Case A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily serum drug levels consistently fell below the therapeutic range, which led the physi…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33780/psn-pdf
    July 01, 2015 - Safety and Medical Education January 1, 2014 Ranji SR. Safety and Medical Education. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/safety-and-medical-education Annual Perspective 2014 As the patient safety field has grown, so too has the appreciation for the need to improve safety in medical educatio…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33851/psn-pdf
    January 01, 2017 - The Weekend Effect January 1, 2017 Ranji SR. The Weekend Effect. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/weekend-effect Annual Perspective 2017 Introduction Anyone who has spent time in a hospital as a patient or staff member may recognize that the availability of services and personnel can va…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49743/psn-pdf
    September 01, 2015 - Dual Therapy Debacle September 1, 2015 Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/dual-therapy-debacle The Case An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction, hyperlipidemia, obesity, and a long history of tobacco use …

  15. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
    January 01, 2015 - Spotlight Case [MONTH] 2003 Spotlight Case February 2007 The ‘Customer’ Is Always Right Source and Credits This presentation is based on the February 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Niraj L. Sehgal,…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33854/psn-pdf
    March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety March 1, 2018 Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety Perspective Errors in hospitals remain a major cause of death.(1…

  17. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
    November 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case November 2008 Dangerous Shift Source and Credits This presentation is based on the November 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Emily S. Patterson, PhD Institute for Ergonomics, Ohi…

  18. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps | PSNet

    psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
    April 24, 2018 - pre-operating room portion includes verifying any required documentation, required radiologic reports or test

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840175/psn-pdf
    November 16, 2022 - Intravenously administered heparin is managed using either a calibrated activated partial thromboplastin test

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49535/psn-pdf
    May 01, 2007 - A test of the methodology with 10 case studies in an academic medical center shows that this novel approach
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