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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43436/psn-pdf
    August 13, 2014 - Decreasing handoff-related care failures in children's hospitals. August 13, 2014 Bigham MT, Logsdon TR, Manicone PE, et al. Decreasing handoff-related care failures in children's hospitals. Pediatrics. 2014;134(2):e572-e579. doi:10.1542/peds.2013-1844. https://psnet.ahrq.gov/issue/decreasing-handoff-related-care-…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38639/psn-pdf
    May 20, 2009 - Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT. May 20, 2009 McCreadie G, Oliver TB. Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particu…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60279/psn-pdf
    April 29, 2020 - Exploring challenges in quality and safety work in nursing homes and home care - a case study as basis for theory development. April 29, 2020 Johannessen T, Ree E, Aase I, et al. Exploring challenges in quality and safety work in nursing homes and home care – a case study as basis for theory development. BMC Healt…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72741/psn-pdf
    February 17, 2021 - The I-READI quality and safety framework: a health system’s response to airway complications in mechanically ventilated patients with Covid-19. February 17, 2021 Ginestra JC, Atkins JH, Mikkelsen ME, et al. The I-READI Quality and Safety Framework: a health system’s response to airway complications in mechanically…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39123/psn-pdf
    April 30, 2014 - Incorrect surgical procedures within and outside of the operating room. April 30, 2014 Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126. https://psnet.ahrq.gov/issue/incorrect-surgical-proced…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40252/psn-pdf
    March 02, 2011 - Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes. March 2, 2011 Hastings SN, Barrett A, Weinberger M, et al. Older Patients' Understanding of Emergency Department Discharge Information and Its Relationship With Adverse Outcomes. J Patient Saf. 2…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46565/psn-pdf
    January 23, 2019 - Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. January 23, 2019 Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017. https://psnet.ahrq.gov/issue/closing-loop-guide-safer-ambulatory-referrals-ehr-era Missed an…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74159/psn-pdf
    December 08, 2021 - Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues. December 8, 2021 Malevanchik L, Wheeler M, Gagliardi K, et al. Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues. . Jt Comm J Qu…

  9. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx Spotlight The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department Source and Credits • This presentation is based on the April 2023 AH…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49813/psn-pdf
    January 01, 2018 - Dying in the Hospital With Advanced Dementia December 1, 2017 Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia Case Objectives Recognize the importance of eliciting patient preferences and go…

  11. Patient as a Team Member in Clinical Care | PSNet

    psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
    March 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Patient as a Team Member in Clinical Care  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybraria…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49632/psn-pdf
    July 01, 2011 - A Seasonal Care Transition Failure July 1, 2011 Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure The Case A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine resident—for routine follow-up…

  13. Double Dosing, by the Rules | PSNet

    psnet.ahrq.gov/web-mm/double-dosing-rules
    February 03, 2010 - Double Dosing, by the Rules Citation Text: Cohen H. Double Dosing, by the Rules. 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 tagg…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33811/psn-pdf
    June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective June 1, 2016 Khudeira Z. Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72739/psn-pdf
    February 10, 2021 - Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism February 10, 2021 McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leadi…

  16. Code Status vs. Care Status | PSNet

    psnet.ahrq.gov/web-mm/code-status-vs-care-status
    September 30, 2020 - SPOTLIGHT CASE Code Status vs. Care Status Citation Text: Krisman RK, Spero H. Code Status vs. Care Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX End…

  17. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism | PSNet

    psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
    December 31, 2024 - SPOTLIGHT CASE Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism Citation Text: McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…

  18. In Conversation with...Barbara Pelletreau and John Riggi about Cybersecurity | PSNet

    psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cybersecurity
    March 27, 2024 - Daily internal meetings with leadership are critical to communicating between critical leads, such as

  19. Slippery Slide Into Life | PSNet

    psnet.ahrq.gov/web-mm/slippery-slide-life
    January 21, 2017 - Slippery Slide Into Life Citation Text: Halamek LP. Slippery Slide Into Life. 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 …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862983/psn-pdf
    February 28, 2024 - Airway Obstruction during Anterior Cervical Spine Surgery February 28, 2024 Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery The Case A 47-year-old obese man (body weight 13…
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