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  1. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience | PSNet

    psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
    December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005  View more articles from the same authors. Citation Text: Conway JB, Weingart SN. Organizational Change…

  2. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
    November 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case November 2006 Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Source and Credits This presentation is based on the November 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33846/psn-pdf
    November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety November 1, 2017 Rozenblum R, Bates DW. The Role of Patient-facing Technologies to Empower Patients and Improve Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-imp…

  4. Misread Label | PSNet

    psnet.ahrq.gov/web-mm/misread-label
    August 28, 2024 - Misread Label Citation Text: Franklin BD. Misread Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850362/psn-pdf
    June 14, 2023 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital June 14, 2023 Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…

  6. Rapid Response Teams: Lessons from the Early Experience | PSNet

    psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
    November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience William S. Krimsky, MD | November 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…

  7. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia | PSNet

    psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
    February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia Citation Text: Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation …

  8. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement | PSNet

    psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
    July 01, 2004 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement Citation Text: Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy…

  9. Chest Tube Complications | PSNet

    psnet.ahrq.gov/web-mm/chest-tube-complications
    September 27, 2023 - Chest Tube Complications Citation Text: Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  10. Are We Pushing Graduate Nurses Too Fast? | PSNet

    psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
    November 16, 2022 - Are We Pushing Graduate Nurses Too Fast? Citation Text: Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  11. Deciphering the Code | PSNet

    psnet.ahrq.gov/web-mm/deciphering-code
    November 16, 2022 - Deciphering the Code Citation Text: Goldstein MK. Deciphering the Code. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…

  12. Hiding in Plain Sight | PSNet

    psnet.ahrq.gov/web-mm/hiding-plain-sight
    April 24, 2019 - Hiding in Plain Sight Citation Text: Weinberg JM. Hiding in Plain Sight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61079/psn-pdf
    October 28, 2020 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication October 28, 2020 Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon- …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60543/psn-pdf
    May 27, 2020 - Wrong Catheter in the Right Patient May 27, 2020 Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-catheter-right-patient The Case  A 55-year-old man with history of emphysema was admitted to the hospital for pneumonia. The patient had two?peripheral…

  15. A Mid-Summer Fog | PSNet

    psnet.ahrq.gov/web-mm/mid-summer-fog
    September 29, 2017 - A Mid-Summer Fog Citation Text: Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  16. Primary Workaround, Secondary Complication | PSNet

    psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
    January 24, 2018 - Primary Workaround, Secondary Complication Citation Text: Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar B…

  17. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences | PSNet

    psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
    December 18, 2019 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences Citation Text: Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…

  18. Diagnostic Delay in the Emergency Department | PSNet

    psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
    September 18, 2024 - Diagnostic error in the emergency department: follow up of patients with minor trauma in the outpatient clinic

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33737/psn-pdf
    September 01, 2012 - Preparing for Health Reform: The Federal Government and the Nursing Workforce September 1, 2012 Buerhaus P. Preparing for Health Reform: The Federal Government and the Nursing Workforce. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce Per…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33584/psn-pdf
    March 15, 2025 - Communication Between Clinicians March 15, 2025 Communication Between Clinicians. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/communication-between-clinicians PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in…
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