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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
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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…
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psnet.ahrq.gov/node/612828/psn-pdf
February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications
February 23, 2022
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
Objectives
Recognition, early evaluation, and management of kidney …
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3
August 1, 2017
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
The Case
A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the
app…
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psnet.ahrq.gov/node/49617/psn-pdf
January 01, 2011 - Failure to Reevaluate
December 1, 2010
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/failure-reevaluate
The Case
A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community
hospital developed methicillin-resistant staphylococc…
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psnet.ahrq.gov/node/49626/psn-pdf
May 01, 2011 - Outbreak
May 1, 2011
Rothman R, Stapleton S. Outbreak. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/outbreak
The Case
A 36-year-old healthy man developed an acute febrile illness associated with a vesicular rash. He
presented to an urgent care clinic where he was diagnosed with varicella infection ("chic…
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psnet.ahrq.gov/node/72837/psn-pdf
September 01, 2022 - Project Nurture Engages Pregnant People with Substance
Use Disorder, Improves Maternal and Infant Outcomes.
Originally published on March 11, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-
improves-maternal-and
Summary
Project…
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psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
January 01, 2015 - Annual Perspective
Patient Safety and Opioid Medications
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2016
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. Ro…
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Do…
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety
December 14, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Dr. Michelle Schreiber on Measuring Patient Safety. PSNet [internet]. 2022.In Conversation With... Dr. Michelle …
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - Measuring Patient Safety
Michelle Schreiber, MD; Cindy Van, MHSA; Sarah E. Mossburg, RN, PhD
| December 14, 2022
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSN…
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psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
November 01, 2011 - VA Surgical Quality Improvement Program (VASQIP) data was assessed for outcomes.( 1 ) A mobile point
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE)
Collaborative Studies and Implements Methods to Prevent
Avoidable Cases of Hospital Associated VTE
April 7, 2022
https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-
implements-methods
Summary
Venous thromboembolism (…
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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…
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psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident
September 28, 2010 - Study
A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1.
Citation Text:
Aboumatar HJ, Blackledge CG, Dickson C, et al. A descriptive study of …
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psnet.ahrq.gov/issue/why-test-results-are-still-getting-lost-follow-qualitative-study-implementation-gaps
June 22, 2022 - Study
Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.
Citation Text:
Zimolzak AJ, Shahid U, Giardina TD, et al. Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps. J Gen Intern Med. 2022;3…
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psnet.ahrq.gov/issue/burden-opioid-related-mortality-united-states
June 02, 2021 - Study
Classic
The burden of opioid-related mortality in the United States.
Citation Text:
Gomes T, Tadrous M, Mamdani MM, et al. The burden of opioid-related mortality in the United States. JAMA Netw Open. 2018;1(2):e180217. doi:10.1001/jamanetworkopen.2018.0217…
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psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error
April 14, 2011 - Review
Emerging Classic
Hierarchy and medical error: speaking up when witnessing an error.
Citation Text:
Peadon R (R), Hurley J, Hutchinson M. Hierarchy and medical error: speaking up when witnessing an error. Safety Sci. 2020;125:104648. doi:10.1016/j.ssci.202…
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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.
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psnet.ahrq.gov/issue/clinical-supervision-general-practice-training-interweaving-supervisor-trainee-and-patient
October 13, 2021 - Study
Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning.
Citation Text:
Sturman N, Parker M, Jorm C. Clinical supervision in general practice training: the interw…