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  1. psnet.ahrq.gov/web-mm/double-trouble
    August 01, 2012 - SPOTLIGHT CASE Double Trouble Citation Text: Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836839/psn-pdf
    March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare Staff March 31, 2022 Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff Introduction The…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33809/psn-pdf
    June 01, 2016 - In Conversation With… Gregg S. Meyer, MD, MSc June 1, 2016 In Conversation With… Gregg S. Meyer, MD, MSc. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc Editor's note: Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based system tha…
  4. psnet.ahrq.gov/web-mm/thin-air
    March 01, 2006 - SPOTLIGHT CASE Thin Air Citation Text: Gaba DM. Thin Air. 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 …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50928/psn-pdf
    February 21, 2020 - Updates in the Role of Health IT in Patient Safety February 21, 2020 Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety Background Health information technology (HIT) has the potential…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846563/psn-pdf
    March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March 2022 conviction of RaDonda Vaught, a former nu…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33736/psn-pdf
    September 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012 In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management at UCLA School of P…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865656/psn-pdf
    April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous Combination April 24, 2024 Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination The Case A 26-ye…
  9. psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
    September 01, 2017 - Missed Patient Assignment: Is Anyone There? Citation Text: Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49865/psn-pdf
    June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy June 1, 2019 Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy The Case A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49732/psn-pdf
    May 01, 2015 - Errors in Sepsis Management May 1, 2015 Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/errors-sepsis-management Case Objectives Define sepsis, severe sepsis, and septic shock. Describe the severe sepsis/septic shock resuscitation bundle. Recognize commonly encou…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33822/psn-pdf
    January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA January 1, 2017 In Conversation With… Paul H. O'Neill, MPA. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa Editor's note: Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prio…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841139/psn-pdf
    December 14, 2022 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. December 14, 2022 Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. PSNet [internet]. 2022. https://psnet.ah…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49600/psn-pdf
    April 01, 2010 - Bad Writing, Wrong Medication April 1, 2010 Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication Case Objectives Differentiate between a medication error and an adverse drug event. Appreciate the system complexities involved in medication erro…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49528/psn-pdf
    January 01, 2015 - The "Customer" Is Always Right February 1, 2007 Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/customer-always-right Case Objectives Understand the importance of identifying a patient's agenda. Appreciate the factors that contribute to unmet patient expectations. …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33807/psn-pdf
    May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD May 1, 2016 In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd Editor's note: Dr. Drew, a nurse researcher, is the David Mortara Distinguished Professor of Physiological Nursing and…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49702/psn-pdf
    March 01, 2014 - Tough Call: Addressing Errors From Previous Providers March 1, 2014 Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers Case Objectives Define what it means to be a professional. Identi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33664/psn-pdf
    March 01, 2008 - In Conversation with...Bradley T. Rosen, MD, MBA March 1, 2008 In Conversation with..Bradley T. Rosen, MD, MBA. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba Editor's note: Dr. Rosen is Medical Director of the Inpatient Specialty Program (ISP) Hospitalist service…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33635/psn-pdf
    July 01, 2006 - In Conversation with...Allan Frankel, MD July 1, 2006 In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this kind of work. Dr. Allan …

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