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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - The Case
A 94-year-old woman with history of congestive heart failure (CHF), hypertension, and gout … Notably, in the last year the patient had been hospitalized 5 times for CHF exacerbations or pneumonia … The Commentary
Take-Home Points
References
Related Resources From the Same Author
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psnet.ahrq.gov/web-mm/missing-suction-tip
January 01, 2006 - Case & Commentary: Part 1 A 65-year-old, 124-kg man with aortic stenosis and coronary artery disease … Louis, MO: Mosby-Year Book; 1995:19-34. 6. Gibbs VC, Auerbach AD. The retained surgical sponge. … : Part 2
Case & Commentary: Part 3
References
Related Resources From the Same Author
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psnet.ahrq.gov/web-mm/complaints-safety-surveillance
May 05, 2021 - The Case A 42-year-old woman presented to the emergency department with abdominal pain. … Sections
The Case
The Commentary
References
Related Resources From the Same Author
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psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - less than half of US
high school students are enrolled in foreign language courses.(6)
In the case description … study comparing hospital
interpreters and ad hoc interpreters, for example, found that when an 11-year-old … Lack of an interpreter for a
3-year-old girl presenting to the emergency department with abdominal pain … by someone else" instead of "the girl hit herself" when she fell off her
tricycle) resulted in a 2-year-old
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psnet.ahrq.gov/curated-library/nurse-wellbeing-and-patient-safety
August 30, 2023 - AHRQ PSNet Team
Date Created: June 5, 2024
Last Updated: July 21, 2025
Description … The author... … with higher psychological safety were more satisfied with their jobs, less likely to leave in the next year … The author discusses TeamSTEPPS and other communication interventions as strategies for improvement.
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psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
August 01, 2015 - The note began at the time of Hippocrates as a narrative description of what the patient was saying. … A wise person once said: we virtually always overestimate what we can do in a year and underestimate … Silicon Valley has figured out in the last year or two that health care is the only part of the economy … Citation
Sections
Perspective
Related Resources From the Same Author
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psnet.ahrq.gov/node/49598/psn-pdf
February 01, 2010 - https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
The Case
A 90-year-old woman who lived … Problem Description
Errors in the drug name, dosage, frequency, and route of administration for home
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - Case & Commentary: Part 1
A 65-year-old, 124-kg man with aortic stenosis and coronary artery disease … Louis, MO: Mosby-Year Book; 1995:19-34.
6. Gibbs VC, Auerbach AD. The retained surgical sponge.
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psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
July 01, 2006 - The next year I was asked to co-chair an IHI collaborative. … The simple description is that if you take human beings with their innate frailties and put them into … Citation
Sections
Perspective
Related Resources From the Same Author … February 3, 2011
Nonpunitive medication error reporting: 3-year findings from one hospital's
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - The Case
A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent … Nov-Dec 2006;6:28-30; author reply W10-22. [go to PubMed]
8. … Sections
The Case
The Commentary
References
Related Resources From the Same Author
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psnet.ahrq.gov/node/49566/psn-pdf
July 01, 2008 - https://psnet.ahrq.gov/web-mm/what-was-those-platelets
The Case
A 47-year-old woman was admitted to … On the same day, a 76-year-old man with coronary artery disease and a prosthetic aortic valve was
admitted … The 47-year-old woman remained critically ill for many days and had Staphylococcus aureus in her
bloodstream … The bacterium was never cultured
from the blood of the 76-year-old man, but he remained febrile in the … Contaminated Platelet Products
(N = 46 transfused platelet units).(14)
Number/Percentage of
Cases
Description
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - PSNet Team
Date Created: September 13, 2021
Last Updated: July 21, 2025
Description … RN, PhD, FAAN |
January 31, 2024
Pregnancy, childbirth, and the postpartum year … to patient safety resulted in improvements in both patient- and provider-related outcomes over a 3-year … Twitter
Linkedin
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Pregnancy, childbirth, and the postpartum year … to patient safety resulted in improvements in both patient- and provider-related outcomes over a 3-year
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psnet.ahrq.gov/node/49670/psn-pdf
November 01, 2012 - https://psnet.ahrq.gov/web-mm/missed-pneumonia
The Case
A 32-year-old man presented to the emergency … 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
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
The Cases
Case #1: A 53-year-old … Case #2: A 68-year-old woman with type 1 diabetes was admitted for elective total knee arthroplasty. … psnet.ahrq.gov//#5
https://psnet.ahrq.gov/issue/obtaining-best-possible-medication-history-hospital-admission-description-pharmacy-technician … https://psnet.ahrq.gov/issue/obtaining-best-possible-medication-history-hospital-admission-description-pharmacy-technician
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psnet.ahrq.gov/perspective/adverse-events-dentistry
December 22, 2020 - around antibiotic and opioid stewardship in dentistry and one of the things that struck me was her description … learned when I came into the school is that the dentists are hands on from the second, third, fourth year … We do a ton of simulations from the first year, simulating how to take a medical history and how to have … Authors
References
Related Resources From the Same Author(s)
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - Case & Commentary: Part 1 An 81-year-old man with chronic obstructive pulmonary disease and end-stage … : Part 1
Case & Commentary: Part 2
References
Related Resources From the Same Author
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - The Case A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture … Problem Description Errors in the drug name, dosage, frequency, and route of administration for home … The Case
The Commentary
References
Figures
Related Resources From the Same Author
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psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - The Case A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area burn … Description of the development and validation of the Canadian Paediatric Trigger Tool. … Medication Errors
Take-Home Points
References
Related Resources From the Same Author
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psnet.ahrq.gov/node/49575/psn-pdf
November 01, 2008 - https://psnet.ahrq.gov/web-mm/sick-and-pregnant
The Case
A 35-year-old woman with chronic asthma presented … Pregnancy
Category
Description Examples
A
Controlled studies show no risk.