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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
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In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/perspective/lesson-vas-team-training-program
November 01, 2011 - Lesson from the VA's Team Training Program
Julia Neily, RN, MS, MPH; Peter D. Mills, PhD, MS; Lisa M. Mazzia, MD; and Douglas E. Paull,MD | November 1, 2011
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Neily J, Mills PD, Pa…
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psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
November 01, 2011 - In Conversation With… Eduardo Salas, PhD
November 1, 2011
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In Conversation With… Eduardo Salas, PhD . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.…
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS
David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS | February 1, 2017
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Baker DP, King HB, Battles J. New Ins…
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
April 10, 2024 - rapidly implement the changes that were aimed at improving safe patient care. 43-45 A Government Accountability
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psnet.ahrq.gov/primer/human-factors-engineering
December 15, 2024 - Human Factors Engineering
Citation Text:
Human Factors Engineering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error
Citation Text:
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/miscalculated-risk
March 01, 2015 - Miscalculated Risk
Citation Text:
Strassels SA. Miscalculated Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/round-trip-service
April 26, 2023 - Round-Trip Service
Citation Text:
McGrath MH. Round-Trip Service. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Emerging Safety Issues in Artificial Intelligence
Robert Challen, MA, MBBS | July 1, 2019
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Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
November 01, 2012 - Defensive Medicine: "Glowing" with Pain
Citation Text:
Sethi MK. Defensive Medicine: "Glowing" with Pain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/49687/psn-pdf
August 21, 2013 - Emergency Error
August 21, 2013
Symons NRA. Emergency Error. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/emergency-error
Case Objectives
State that emergency surgery is high risk and has high mortality.
Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of
…
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psnet.ahrq.gov/node/60376/psn-pdf
July 30, 2020 - COVID-19: Team and Human Factors to Improve Safety
July 30, 2020
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
Background
The rapid transmission of COVID-19 has resulted in an international pandem…
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - One Bronchoscopy, Two Errors
Citation Text:
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/dropped-no
October 30, 2019 - The Dropped "No"
Citation Text:
Johnson AJ. The Dropped "No". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/liposuction-gone-awry
July 01, 2003 - Liposuction Gone Awry
Citation Text:
Yates JA. Liposuction Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - Treatment Challenges After Discharge
November 1, 2010
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
Case Objectives
Understand types and frequencies of adverse events occurring between patient discharge from the
hospital …
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Diagnostic Overshadowing Dangers
Citation Text:
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
October 01, 2011 - SPOTLIGHT CASE
Abdominal Aortic Aneurysm Screening
Citation Text:
Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - Discontinued Medications: Are They Really Discontinued?
Citation Text:
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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