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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - December 10, 2014
Smart pumps: advanced capabilities and continuous quality improvement
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - intensive care unit (ICU) presence and specialist staffing, strong safety culture, and high technology capabilities
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - supervising attending without an established trainee relationship to thoroughly assess the learner's capabilities
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - Electronic Health Records
December 15, 2024
Electronic Health Records. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/electronic-health-records
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - Hemolysis Holdup
May 1, 2017
Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic
kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
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psnet.ahrq.gov/node/33755/psn-pdf
September 01, 2013 - What We've Learned About Leveraging Leadership and
Culture to Affect Change and Improve Patient Safety
September 1, 2013
Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve
Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
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psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - explicit communication with multiple
parties to fully understand the patient’s baseline and cognitive
capabilities
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - skill as independent practitioners to diagnose and treat illnesses and the paramedics’ rapid response
capabilities
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - experience a loss of confidence and self-esteem, and further question their own judgment and decision-making capabilities
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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/49645/psn-pdf
February 01, 2012 - depends on the coordinated actions of many
stakeholders and the continuing evolution of standards, capabilities
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psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - any purpose) ranging
from 72%–94%.(3-4)
Mobile device uses in clinical care vary depending on the capabilities
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psnet.ahrq.gov/node/33768/psn-pdf
June 01, 2014 - from a policy planner's perspective,
the lesson is that it's a mistake to judge someone's potential capabilities
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - available data, the quality of
care in many SNFs appears to be improving (2), but the medical and nursing capabilities
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psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
September 01, 2017 - need to quickly build rapport and assess each other's clinical knowledge, experience, and technical capabilities
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psnet.ahrq.gov/node/857060/psn-pdf
November 27, 2023 - The Role of Undergraduate Nursing Education in Patient
Safety
November 27, 2023
Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
Introduction
Nurses are a li…
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psnet.ahrq.gov/node/49824/psn-pdf
March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous
Delay
March 1, 2018
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
The Case
A 35-year-old woman with no prior cardiac history calle…
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psnet.ahrq.gov/web-mm/lap-burn
March 01, 2018 - Lap Burn
Citation Text:
Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Cita…
-
psnet.ahrq.gov/node/33631/psn-pdf
April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to
Promote a Culture of Safety
April 1, 2006
Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a
Culture of Safety. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - Suicide Risk in the Hospital
May 1, 2018
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/suicide-risk-hospital
The Case
A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder
presented to the emergency department (ED)…