-
psnet.ahrq.gov/node/49467/psn-pdf
December 01, 2004 - weak-response
The Case
A primary care physician on call for his group received a call at 9:00PM from a 68-year-old … The patient
reported also taking lisinopril 20 mg daily for more than a year. … As I tried to get a visual picture from
his description, he mentioned that he had a digital camera.
-
psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Case #1: A 35-year-old … Case #2: A 56-year-old female was sent to the Emergency Department (ED) from a skilled nursing facility … Pasero Opioid-induced Sedation Scale (POSS)4-6
Description Intervention
S Sleeping, easy to arouse … psnet.ahrq.gov//#3
https://psnet.ahrq.gov//#2
https://psnet.ahrq.gov//#4
https://psnet.ahrq.gov//#4
Description
-
psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - The nurse notified the covering resident, giving him a concise description of the patient, her primary … patient safety goals of many organizations.( 6 ) Although the nurse caring for the patient gave a concise description … The Case
The Commentary
References
Figure
Related Resources From the Same Author
-
psnet.ahrq.gov/node/49783/psn-pdf
February 01, 2017 - The Case
A 55-year-old woman with a history of metastatic cancer of unknown origin was sent to the emergency … Indeed, it can be inferred from this case description that the care provider
herself realized the inappropriateness … A description of the steps that should be taken to develop, design,
implement, approve and maintain
-
psnet.ahrq.gov/web-mm/security-lapse
December 18, 2019 - Within hours, the office contacted the student for further description of the violation, and within a … Sections
The Case
The Commentary
References
Related Resources From the Same Author
-
psnet.ahrq.gov/node/49460/psn-pdf
September 01, 2004 - Within hours, the office contacted the student for further description of
the violation, and within
-
psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - Most hospitals already receive thousands of reports per year. … They're not going to do that 100 times a year, they're probably not even going to do it 40 times a year … And you can get away with that for a year or two. … investment up front of somebody who's knowledgeable reviewing the incident, even just the actual briefest description … Citation
Sections
Perspective
Related Resources From the Same Author
-
psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - Case & Commentary: Part 1
A 61-year-old male with a history of chronic pancreatitis and cardiomyopathy … Notification of security with a description of the missing patient and pertinent clinical information … Case & Commentary: Part 2
References
Table
Related Resources From the Same Author … (s)
Description and evaluation of an interprofessional patient safety course for health
-
psnet.ahrq.gov/web-mm/missed-pneumonia
June 01, 2005 - The Case A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right … The Commentary Every year, more than 4 million Americans are diagnosed with community-acquired pneumonia … current patient was "diagnosed" with "fever, pleural effusion, and chest wall pain," representing a description … The Case
The Commentary
References
Table
Related Resources From the Same Author
-
psnet.ahrq.gov/curated-library/organizational-learning
July 21, 2025 - PSNet Team
Date Created: March 21, 2024
Last Updated: July 21, 2025
Description … presents evidence of poor quality care and significant waste (to the tune of an estimated $750 billion per year … presents evidence of poor quality care and significant waste (to the tune of an estimated $750 billion per year … The author, who has extensively analyzed high-profile failures in many industries, recommends that organizations
-
psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - Case & Commentary: Part 1
A 50-year-old man was diagnosed with chronic hepatitis C (viral load of 2,500,000 … Regulatory Process
Description
Credentialing
Usually a local process that determines … Case & Commentary: Part 2
References
Table
Related Resources From the Same Author
-
psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - postoperative period
Understand the approaches for managing cervical hematomas
The Cases
Case #1: A 61-year-old … Case #2: A 52-year-old woman with a chronic cough attributed to COVID-19 pneumonia one year earlier … Risk factors for neck hematoma after thyroid or parathyroid surgery: ten-year analysis of the nationwide … The Commentary
Take-Home Points
References
Related Resources From the Same Author … &M Cases
Nothing Called Small Surgery
August 26, 2020
Description
-
psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old … Case #2: A 49-year-old male patient with history of poorly controlled type 1 diabetes, homelessness, … psnet.ahrq.gov//#9
https://psnet.ahrq.gov/issue/obtaining-best-possible-medication-history-hospital-admission-description-pharmacy-technician
-
psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Takeda Speaker
Inhibrix Consultant
Boehinger Ingelheim Consultant
Astra Zeneca Consultant
Theravance Author … Inhibrix Author
https://psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture … The Case
A 56-year-old man was admitted with Coronavirus Disease 2019 (COVID-19) pneumonia and acute … A large study of tracheostomy-related deaths
over a 10-year period in the US found a higher prevalence … ventilator dependence and progressive dilation of the trachea at
the tracheostomy tube cuff site.9,10 The description
-
psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - suicidal ideation when screened in the ED.3 In addition, there are
approximately 420,000 ED visits every year … Description of the Innovative Activity
The ED-SAFE study was designed to assess the effect of universal … Researchers wanted to determine the rate of suicide for these patients up to one year
after discharge … The Coping Long Term with Active Suicide Program (CLASP):
description and pilot data. … Health care contacts in the year before suicide death.
-
psnet.ahrq.gov/periodic-issue/periodic-issue-469
December 31, 2024 - Management (EM) and Error Avoidance (EA)— on cardiopulmonary resuscitation (CPR) performance among first-year … Management (EM) and Error Avoidance (EA)— on cardiopulmonary resuscitation (CPR) performance among first-year … Emergency Jaenic Lee, MD, Josh Fernelius, MD and William Frick, MD | December 31, 2024
A 55-year-old … Lewis, MD | December 31, 2024
A 54-year-old man with a history of tobacco use presented to the emergency
-
psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
November 25, 2020 - The Case A 56-year-old woman was brought to the emergency department (ED) by her husband for “shaking … perforation is considered rare due to the relative paucity of case reports, since its first dramatic description … The Commentary
Take-Home Points
References
Related Resources From the Same Author
-
psnet.ahrq.gov/node/33589/psn-pdf
September 15, 2024 - Characteristics of High Reliability1,2,3,4
Characteristic Description
Preoccupation
With Failure … decrease in adverse events
such as falls, pressure injuries, and healthcare-acquired infections one year
-
psnet.ahrq.gov/node/854849/psn-pdf
October 31, 2023 - web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
The Cases
Case #1: A 56-year-old … Case #2: A 38-year-old man was brought to the hospital with altered mental status after crashing while … concepts that were verbalized during the visit, starting with the patient’s history
and the provider’s description … Policy, Payment, and Quality Provisions Changes
to the Medicare Physician Fee Schedule for Calendar Year … fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year
-
psnet.ahrq.gov/node/49536/psn-pdf
May 01, 2007 - The nurse notified the covering resident, giving him a concise description of the
patient, her primary … patient safety goals of many organizations.(6) Although the nurse caring for the
patient gave a concise description