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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - Annual Perspective
Ensuring Patient and Workforce Safety Culture in Healthcare
John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg
| March 27, 2024
View more articles from the same authors.
Citation Text:
Murray J, Sorra J, Gale B, et al. Ensuring Patient…
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.
Citation Text:
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.. PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
September 01, 2017 - Assessing the Safety of Electronic Health Records: What Have We Learned?
Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH | September 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Sittig DF, Singh H. Assessing the Safe…
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psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
March 28, 2023 - Maternal Safety and Perinatal Mental Health
Christie Allen, MSN, RNC-NIC, CPHQ, C-ONQS, Cindy Manaoat Van, MHSA, Sarah E. Mossburg, RN, PhD
| March 29, 2023
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Allen C, Van CM, …
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psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges
Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Conversation
View more articles from the…
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psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schuelke-about-virtual-nursing
August 30, 2023 - In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing
Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Essay
View more articles from the …
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psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal-mental-health
March 29, 2023 - In Conversation with... Christie Allen about Maternal Safety and Perinatal Mental Health
March 28, 2023
Also Read the Essay
Citation Text:
In Conversation with.. Christie Allen about Maternal Safety and Perinatal Mental Health. PSNet [internet]. 2023.In Conversat…
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psnet.ahrq.gov/node/33815/psn-pdf
September 01, 2016 - Telemedicine and Patient Safety
September 1, 2016
Agboola SO, Kvedar JC. Telemedicine and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
Perspective
A paradigm shift is ongoing in the health care sector. The traditional model of episodic and hospital-base…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
December 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case December 2007
Elopement
Source and Credits
This presentation is based on the December 2007 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Debra Gerardi, RN, MPH, JD
Creighton University School of Law
Ed…
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psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - Listen to the Family
June 1, 2004
Campbell D. Listen to the Family. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/listen-family
The Case
Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The
surgical resident examined the patient, an elderly woman with …
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psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - Benefits vs. Risks of Intraosseous Vascular Access
August 21, 2014
Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
The Case
A 72-year-old woman with a history of asthma, congestive heart…
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psnet.ahrq.gov/node/841468/psn-pdf
December 14, 2022 - Don’t Bite Your Tongue.
December 14, 2022
Singh NS. Don’t Bite Your Tongue. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/dont-bite-your-tongue
The Case
A 63-year-old woman with a past medical history of hypertension, osteoarthritis, migraine headaches, and
daily smoking was admitted to a hospital for ant…
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psnet.ahrq.gov/node/33868/psn-pdf
October 01, 2018 - Safety in the Retail Pharmacy
October 1, 2018
Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-retail-pharmacy
Perspective
There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each
year.(1) Many patients interact w…
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Is the Admission Drug Dose Too Low?
August 1, 2009
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
The Case
A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to
the hospit…
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psnet.ahrq.gov/node/843736/psn-pdf
February 01, 2023 - Saved by ECMO
February 1, 2023
Weiss NA. Saved by ECMO . PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/saved-ecmo
The Case
A 27-year-old pregnant woman was admitted at an estimated gestational age (EGA) of 29 weeks for
increased shortness of breath. She was diagnosed with severe pulmonary arterial hyperte…
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psnet.ahrq.gov/node/49510/psn-pdf
May 01, 2006 - Cups of Error
May 1, 2006
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/cups-error
The Case
An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered
from dementia, he remained alert and oriented with only mild short-term memory…
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psnet.ahrq.gov/node/33844/psn-pdf
October 01, 2017 - Health Care Worker Presenteeism: A Challenge for Patient
Safety
October 1, 2017
Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
Perspective
Introduction
Health care–as…
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psnet.ahrq.gov/node/33679/psn-pdf
January 01, 2009 - Disclosure of Medical Error
January 1, 2009
Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/disclosure-medical-error
Perspective
Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts
advocate that greater discl…