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8861. Secured But Not Always Safe | PSNet
      psnet.ahrq.gov/web-mm/secured-not-always-safe
      October 01, 2015 - Secured But Not Always Safe Citation Text: Jahr JS, Hosseini P. Secured But Not Always Safe. 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 …

8862. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49770/psn-pdf
      September 01, 2016 - Wrong-Time Error With High-Alert Medication September 1, 2016 Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication The Case A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…

8863. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49649/psn-pdf
      March 01, 2012 - Cultural Dimensions of Depression March 1, 2012 Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression The Case A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability to breathe and swallow…

8864. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33779/psn-pdf
      March 01, 2015 - Handoffs and Transitions January 22, 2014 Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/handoffs-and-transitions Annual Perspective 2014 Despite recent efforts to promote clinical integration, the United States health care system remains highly fragmented. From it…

8865. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49757/psn-pdf
      April 01, 2016 - Situational Awareness and Patient Safety April 1, 2016 Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety The Case A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…

8866. In Conversation With... Freya Spielberg, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
      September 28, 2022 - Through primary care, patients can develop a long-standing relationship with their clinician and receive … Patient-clinician communication Coordination across settings of care Continuity of care Access to care

8867. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853774/psn-pdf
      September 27, 2023 - Delayed Evaluation of Abdominal Pain in an Elderly Patient. September 27, 2023 Klimkiv L, Utter GH, Barnes DK. Delayed Evaluation of Abdominal Pain in an Elderly Patient. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient The Case An 85-year-old woman presente…

8868. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867656/psn-pdf
      February 26, 2025 - Think about a clinician getting 15 different alerts all the time; that causes alert fatigue.

8869. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836976/psn-pdf
      April 27, 2022 - Intraosseous Line Extravasation in a Pediatric Trauma Patient April 27, 2022 Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient Disclosure of Relevant Financial Relationship…

8870. Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up | PSNet
      psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
      September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up Citation Text: Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…

8871. Monitoring Fetal Health | PSNet
      psnet.ahrq.gov/web-mm/monitoring-fetal-health
      September 08, 2010 - Unlike traditional paper tracings where a clinician can quickly scan 30 minutes or more of activity,

8872. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840255/psn-pdf
      November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions November 16, 2022 Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions . PSNet [internet]. 2022. https://psnet.ahrq.gov/perspecti…

8873. Hold the tPA | PSNet
      psnet.ahrq.gov/web-mm/hold-tpa
      July 29, 2020 - Hold the tPA Citation Text: Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

8874. Cups of Error | PSNet
      psnet.ahrq.gov/web-mm/cups-error
      January 12, 2011 - Cups of Error Citation Text: Blegen MA, Pepper GA. Cups of Error. 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 PubMedId RIS…

8875. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867652/psn-pdf
      February 26, 2025 - The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis Introduction Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…

8876. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846935/psn-pdf
      March 29, 2023 - Maternal Safety and Perinatal Mental Health March 29, 2023 Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health Maternal patient safety is a critical aspect of healthcare given the complex pr…

8877. X-ray Flip | PSNet
      psnet.ahrq.gov/web-mm/x-ray-flip
      August 10, 2019 - X-ray Flip Citation Text: Shapiro MJ. X-ray Flip. 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 Downl…

8878. DNR in the OR and Afterwards | PSNet
      psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
      July 01, 2003 - DNR in the OR and Afterwards Citation Text: Lo B. DNR in the OR and Afterwards. 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 tagge…

8879. Anesthesia: A Weighty Issue | PSNet
      psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
      September 01, 2006 - Anesthesia: A Weighty Issue Citation Text: Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

8880. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49465/psn-pdf
      December 22, 2021 - Electronic Err October 1, 2004 Tang PC. Electronic Err. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/electronic-err The Case A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest pain that that had not responded to three sublingual nitroglycerin tablets at…