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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - Pacing threshold testing induced ventricular fibrillation following acute rate control of atrial fibrillation
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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - Gathering and processing information, such as findings on the clinical
examination and laboratory testing
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psnet.ahrq.gov/node/74021/psn-pdf
October 25, 2021 - Most community pharmacies today also provide immunizations, they provide
point-of-care testing, and
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psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - Testing it in medicine has been relatively limited, but a couple of studies now have shown as
long as
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psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - Making it stick: developing and testing the difficult intravenous access (DIVA) tool.
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psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - recommendations for training and credentialing procedures consisting of specific online curriculum, testing
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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…
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psnet.ahrq.gov/node/33757/psn-pdf
October 01, 2013 - Safety in Radiology
October 1, 2013
Pinto A. Safety in Radiology. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/safety-radiology
Perspective
The use of medical imaging to depict and to help diagnose illness and injury as well as to guide therapeutic
interventions has expanded greatly during the past …
-
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 …
-
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…
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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…
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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…
-
psnet.ahrq.gov/node/49766/psn-pdf
August 21, 2016 - Getting the (Right) Doctor, Right Away
August 21, 2016
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
The Case
A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery.
Postop…
-
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…
-
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…
-
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…
-
psnet.ahrq.gov/primer/never-events
June 15, 2024 - Never Events
Citation Text:
Never Events. 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 Cita…
-
psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - Alert Fatigue
Citation Text:
Alert Fatigue. 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 Ci…
-
psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - greater
impulsivity, slower cognitive processing, and impaired executive function.14 On psychomotor testing
-
psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - greater impulsivity, slower cognitive processing, and impaired executive function. 14 On psychomotor testing