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3641. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867770/psn-pdf
      March 01, 2022 - Toolkit for Decolonization of Non-ICU Patients with Devices. March 1, 2022 Agency for Healthcare Research and Quality. Toolkit for Decolonization of Non-ICU Patients with Devices. https://psnet.ahrq.gov/issue/toolkit-decolonization-non-icu-patients-devices Healthcare associated infection is a persistent contributo…

3642. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43360/psn-pdf
      September 29, 2017 - Antimicrobial Stewardship Toolkit. September 29, 2017 Chicago, IL: American Hospital Association Physician Leadership Forum; July 2014. https://psnet.ahrq.gov/issue/antimicrobial-stewardship-toolkit Antimicrobial stewardship has been promoted as an element of patient safety. This toolkit provides resources for hos…

3643. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47675/psn-pdf
      November 28, 2023 - SOPS Surveys. November 28, 2023 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/sops-surveys Surveys are established mechanisms for organizational assessment of safety culture. This collection of webinars provides an overview of the AHRQ Surveys on Patient Safety Culture™ (SOPS®) and a ran…

3644. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49709/psn-pdf
      May 01, 2014 - Raise the Bar May 1, 2014 Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/raise-bar The Case A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The patient was seen and evaluated by an anesthesiologist who was new to the cente…

3645. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866846/psn-pdf
      September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 24, 2024 Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/zero…

3646. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49424/psn-pdf
      November 01, 2003 - Waiting Too Long November 1, 2003 Rosen MA. Waiting Too Long. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/waiting-too-long The Case A 31-year-old gravida 1, para 1 woman presented at 40 weeks in the early stages of labor having received limited prenatal care at an outside clinic. Physical exam performed…

3647. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49391/psn-pdf
      February 01, 2003 - When "Psychiatric" Symptoms Are Not February 1, 2003 Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not The Case A 70-year-old man without documented past psychiatric history was placed on an involuntary hold as a danger to oth…

3648. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49680/psn-pdf
      March 01, 2013 - Pathologic Mistake March 1, 2013 Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pathologic-mistake The Case A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The discomfort worsened with eating. After losing 15 pounds …

3649. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49851/psn-pdf
      January 01, 2019 - One Bronchoscopy, Two Errors January 1, 2019 Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors The Case A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic respiratory failure…

3650. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49601/psn-pdf
      April 01, 2010 - Nosy Business April 1, 2010 Orlandi RR. Nosy Business. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/nosy-business The Case   A 59-year-old man with a history of idiopathic thrombocytopenic purpura (ITP) presented to the emergency department (ED) with epistaxis (a "nose bleed"). He reported no previous h…

3651. Misleading Complaint | PSNet
      psnet.ahrq.gov/web-mm/misleading-complaint
      December 01, 2009 - Misleading Complaint Citation Text: Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …

3652. Individual Clinician Performance Issues | PSNet
      psnet.ahrq.gov/primer/individual-clinician-performance-issues
      March 15, 2025 - Individual Clinician Performance Issues Citation Text: Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

3653. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60746/psn-pdf
      July 29, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy July 29, 2020 Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy The Case A 28-year-old woman arrived at the Emergency Department (ED) complaining o…

3654. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60066/psn-pdf
      March 25, 2020 - No further nursing assessments or vital signs were recorded until 5:40am when the patient became increasingly

3655. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care | PSNet
      psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
      November 25, 2020 - No further nursing assessments or vital signs were recorded until 5:40am when the patient became increasingly

3656. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47556/psn-pdf
      November 28, 2018 - Improving Diagnosis. November 28, 2018 Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70. https://psnet.ahrq.gov/issue/improving-diagnosis This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights from experts about how to improve diagnosis, t…

3657. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43800/psn-pdf
      August 02, 2016 - Patient Safety Culture: Theory, Methods and Application. August 2, 2016 Waterson P, ed. London, UK: Ashgate; 2014. ISBN: 9781409448143. https://psnet.ahrq.gov/issue/patient-safety-culture-theory-methods-and-application This publication covers patient safety culture including its background in high-risk industries, …

3658. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50633/psn-pdf
      November 06, 2019 - Findings of Two Inaugural Leapfrog Surveys 2019. November 6, 2019 Washington DC: Leapfrog Group; 2019. https://psnet.ahrq.gov/issue/findings-two-inaugural-leapfrog-surveys-2019 Ambulatory surgery centers (ASC) are established venues for surgical care despite engagement in assessment to ensure their safety. This re…

3659. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41442/psn-pdf
      May 30, 2012 - Radiation Therapy Safety: The Critical Role of the Radiation Therapist. May 30, 2012 Odle TG, Rosier N. Albuquerque, NM: American Society of Radiologic Technologists Education and Research Foundation; 2012. https://psnet.ahrq.gov/issue/radiation-therapy-safety-critical-role-radiation-therapist Summarizing the rol…

3660. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37951/psn-pdf
      May 26, 2011 - The Leapfrog Group's CPOE standard and evaluation tool. May 26, 2011 Metzger JB, Welebob E, Turisco F, et al. Patient Saf Qual Healthc. July/August 2008;5:22-25. https://psnet.ahrq.gov/issue/leapfrog-groups-cpoe-standard-and-evaluation-tool This article describes an evaluation tool designed for…