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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49592/psn-pdf
    October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49722/psn-pdf
    December 01, 2014 - Medical Devices in the "Wild" December 1, 2014 Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/medical-devices-wild The Case A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes, chronic pain, arthritis, and…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49436/psn-pdf
    February 26, 2004 - Transfusion "Slip" February 1, 2004 Kaplan HS. Transfusion "Slip". PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/transfusion-slip The Case A married couple, Mr. and Mrs. M, was brought to the emergency department (ED) of a Level 1 trauma center after a half-ton truck that had skidded out of control struck…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73999/psn-pdf
    October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49459/psn-pdf
    September 01, 2004 - Caution, Interrupted September 1, 2004 Wears RL. Caution, Interrupted. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/caution-interrupted The Case A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and neutropenia presented to the emergency department (ED) with …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49401/psn-pdf
    May 01, 2003 - Suicidal Man With Gun May 1, 2003 Simon RI. Suicidal Man With Gun. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/suicidal-man-gun The Case The patient is a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe depression that had persisted for nearly 2 years. On initial inter…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72587/psn-pdf
    December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability December 23, 2020 Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49423/psn-pdf
    November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49691/psn-pdf
    September 01, 2013 - DRESSed for Failure September 1, 2013 Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dressed-failure The Case A 60-year-old woman who uses a wheelchair presented to the emergency department (ED) with right hand cellulitis and an uncomplicated urinary tract infec…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49711/psn-pdf
    June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of Patient Wandering June 1, 2014 Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering Case Objectives Define patie…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33699/psn-pdf
    August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers August 1, 2010 Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers Perspective Academic medical…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49739/psn-pdf
    August 21, 2015 - Breathe Easy: Safe Tracheostomy Management August 21, 2015 Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management The Case A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49674/psn-pdf
    December 01, 2012 - Preventing PICC Complications: Whose Line Is It? December 1, 2012 Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it The Case A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49625/psn-pdf
    May 01, 2011 - Pocket Syringe Swap May 1, 2011 Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/pocket-syringe-swap The Case A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for postoperative pain management. Surgery proceeded uneventfully under…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33831/psn-pdf
    April 01, 2017 - Not necessarily in severe ways, but through the kinds of behaviors that frontline caregivers perceive … If you don't have equally transparent and equitable ways of judging and moving those situations into … demonstrate that no matter how you're paid, if you understand how you're paid, you can focus these tools in ways
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38108/psn-pdf
    September 30, 2014 - No more blame & shame: developing event-reporting systems may go a long way to reducing patient care errors in EMS. September 30, 2014 Rajasekaran K, Fairbanks RJ, Shah M. No more blame & shame. Developing event-reporting systems may go a long way to reducing patient care errors in EMS. EMS magazine. 2008;37(9):61…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41018/psn-pdf
    December 21, 2011 - What stands in the way of technology-mediated patient safety improvements? A study of facilitators and barriers to physicians' use of electronic health records. December 21, 2011 Holden RJ. What stands in the way of technology-mediated patient safety improvements?: a study of facilitators and barriers to physician…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46279/psn-pdf
    August 02, 2017 - Recognizing the ordinary as extraordinary: insight into the "way we work" to improve patient safety outcomes. August 2, 2017 Henneman EA. Recognizing the Ordinary as Extraordinary: Insight Into the "Way We Work" to Improve Patient Safety Outcomes. Am J Crit Care. 2017;26(4):272-277. doi:10.4037/ajcc2017812. https:…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47230/psn-pdf
    August 15, 2018 - Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical departments. August 15, 2018 François P, Lecoanet A, Caporossi A, et al. Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical departments. PLoS One. 2018;13(7…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43744/psn-pdf
    December 03, 2014 - Mobile physician reporting of clinically significant events—a novel way to improve handoff communication and supervision of resident on call activities. December 3, 2014 Nabors C, Peterson SJ, Aronow WS, et al. Mobile physician reporting of clinically significant events-a novel way to improve handoff communication…

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