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8021. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49631/psn-pdf
      July 01, 2011 - Patient Safety and Adherence to Self-Administered Medications July 1, 2011 Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications The Case A 30-year-o…

8022. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49814/psn-pdf
      December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation Mishap December 1, 2017 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap The Case A 63-year-old man with a history of coronary…

8023. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49438/psn-pdf
      March 05, 2004 - OR Peeping March 1, 2004 Mackenzie CF. OR Peeping. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/or-peeping The Case A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete spontaneous abortion (miscarriage). At this community hospital, a new operating room (OR) su…

8024. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49507/psn-pdf
      April 01, 2006 - Is the "Surgical Personality" a Threat to Patient Safety? April 1, 2006 Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety? PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety Case Objectives Describe the myth of the "surgical personality" Identify featu…

8025. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73643/psn-pdf
      August 01, 2022 - ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay August 25, 2021 https://psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled- nursing Summary ECHO-Care Transitions (ECHO-CT) intends to ensure cont…

8026. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49471/psn-pdf
      December 01, 2004 - Carpe Diem (Seize the Day) December 1, 2004 Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day The Case A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic medical conditions including hypertension, h…

8027. Spotlight (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
      May 01, 2018 - Spotlight Spotlight Out of Sight, Out of Mind: Out-of-Office Test Result Management 1 Source and Credits This presentation is based on the May 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Eric Poon, MD, MPH, Duke University School o…

8028. Critical Radiology Alert Process | PSNet
      psnet.ahrq.gov/innovation/critical-radiology-alert-process
      November 16, 2022 - Critical Radiology Alert Process Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL October 30, 2024 View more articles from the same authors. Innovation Contact …

8029. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33564/psn-pdf
      March 15, 2025 - Computerized Provider Order Entry March 15, 2025 Computerized Provider Order Entry. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/computerized-provider-order-entry PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice…

8030. Lethal Cap | PSNet
      psnet.ahrq.gov/web-mm/lethal-cap
      December 19, 2018 - Lethal Cap Citation Text: Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Do…

8031. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? | PSNet
      psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
      June 24, 2020 - SPOTLIGHT CASE Fatal Error in Neonate: Does "Just Culture" Provide an Answer? Citation Text: Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …

8032. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60790/psn-pdf
      February 23, 2022 - COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care February 23, 2022 Kalenderian E, Spallek H, Franklin A, et al. COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-oppor…

8033. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. | PSNet
      psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
      October 31, 2023 - SPOTLIGHT CASE Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. Citation Text: Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…

8034. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74120/psn-pdf
      November 30, 2021 - Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care November 30, 2021 Spero H, Usher AE, Howard B, et al. Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care . PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/culture-clash-no-mo…

8035. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74830/psn-pdf
      June 01, 2022 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications February 23, 2022 https://psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-co…

8036. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843234/psn-pdf
      January 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. February 1, 2023 Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive D…

8037. Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine. | PSNet
      psnet.ahrq.gov/issue/creating-high-reliability-health-care-system-improving-performance-core-processes-care-johns
      January 27, 2016 - Study Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine. Citation Text: Pronovost P, Armstrong M, Demski R, et al. Creating a high-reliability health care system: improving performance on core processes of care at Jo…

8038. Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults. | PSNet
      psnet.ahrq.gov/issue/potentially-inappropriate-medication-use-associated-increased-risk-incident-disability
      October 19, 2022 - Study Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults. Citation Text: Lockery JE, Collyer TA, Woods RL, et al. Potentially inappropriate medication use is associated with increased risk of incident disability in he…

8039. Does teamwork improve performance in the operating room? A multilevel evaluation. | PSNet
      psnet.ahrq.gov/issue/does-teamwork-improve-performance-operating-room-multilevel-evaluation
      July 02, 2014 - Study Does teamwork improve performance in the operating room? A multilevel evaluation. Citation Text: Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-42. Copy Citat…

8040. Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. | PSNet
      psnet.ahrq.gov/issue/incidence-nature-and-causes-avoidable-significant-harm-primary-care-england-retrospective
      November 13, 2019 - Study Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. Citation Text: Avery AJ, Sheehan C, Bell BG, et al. Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note …