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4741. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36824/psn-pdf
      October 03, 2017 - Department of Defense (DoD) Patient Safety Program. October 3, 2017 US Department of Defense; DOD https://psnet.ahrq.gov/issue/department-defense-dod-patient-safety-program This Web site includes information on several initiatives within the US Military Health System to support its culture of safety and reduce med…

4742. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36861/psn-pdf
      November 23, 2016 - Patients as Partners: How to Involve Patients and Families in Their Own Care. November 23, 2016 McGreevey M. Oakbrook Terrace, IL: Joint Commission Resources: 2006. ISBN 9780866889964. https://psnet.ahrq.gov/issue/patients-partners-how-involve-patients-and-families-their-own-care This book illustrates how health c…

4743. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41786/psn-pdf
      October 24, 2012 - Minnesota hospitals are testing ways to reduce return trips. October 24, 2012 Lerner M. Lerner M. Star Tribune. October 11, 2012. https://psnet.ahrq.gov/issue/minnesota-hospitals-are-testing-ways-reduce-return-trips This newspaper article reports on how transition coaches can help improve transfer and discharge c…

4744. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35727/psn-pdf
      February 22, 2006 - Risk of medication errors at hospital discharge and barriers to problem resolution. February 22, 2006 Enguidanos SM; Brumley RD. https://psnet.ahrq.gov/issue/risk-medication-errors-hospital-discharge-and-barriers-problem-resolution The authors reviewed discharge medication records for elderly patients to assess do…

4745. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36161/psn-pdf
      February 17, 2011 - Language barriers to health care in the United States. February 17, 2011 Flores G. Language barriers to health care in the United States. N Engl J Med. 2006;355(3):229-31. https://psnet.ahrq.gov/issue/language-barriers-health-care-united-states The author discusses how language barriers can compromise a patient's h…

4746. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36073/psn-pdf
      September 28, 2010 - Patient safety: through the eyes of your peers. September 28, 2010 Bry K, Stettner B, Marks J. Patient safety: through the eyes of your peers. Nurs Manage. 2006;37(6):20-24. https://psnet.ahrq.gov/issue/patient-safety-through-eyes-your-peers The authors present a peer review model for analyzing nursing behavior and…

4747. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38881/psn-pdf
      November 08, 2012 - Are patients in part to blame when doctors miss the diagnosis? November 8, 2012 Chen PW https://psnet.ahrq.gov/issue/are-patients-part-blame-when-doctors-miss-diagnosis This column recounts a case of delayed diagnosis and examines how communication and process of care failures can contribute to diagnostic errors.…

4748. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41842/psn-pdf
      March 08, 2015 - Patient safety in the OR. March 8, 2015 Stempniak M. Patient safety in the OR. Hospitals & health networks. 2012;86(10):8 p following 40. https://psnet.ahrq.gov/issue/patient-safety-or-0 This article examines patient safety concerns in the operating room, including their causes and how teamwork, checklists, and im…

4749. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35895/psn-pdf
      August 24, 2018 - Building a case for medication reconciliation. August 24, 2018 ISMP Medication Safety Alert! Acute care edition. April 21, 2005. https://psnet.ahrq.gov/issue/building-case-medication-reconciliation This article presents examples of medication errors caused by failed communication, briefly reviews the steps for med…

4750. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40426/psn-pdf
      May 04, 2011 - Doctors could learn something about medical handoffs from the Navy. May 4, 2011 Parikh R. Los Angeles Times. April 18, 2011. https://psnet.ahrq.gov/issue/doctors-could-learn-something-about-medical-handoffs-navy This newspaper article describes how structured communication techniques borrowed from other fields co…

4751. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40669/psn-pdf
      August 27, 2013 - STate Action on Avoidable Rehospitalizations. August 27, 2013 Institute for Healthcare Improvement. 2009 -2013. https://psnet.ahrq.gov/issue/state-action-avoidable-rehospitalizations This Web site supports an initiative to reduce avoidable rehospitalizations by improving transitions in care and communication betwe…

4752. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36217/psn-pdf
      March 04, 2015 - Will saying "I'm sorry" prevent a malpractice lawsuit? March 4, 2015 Berlin L. Will Saying "I'm Sorry" Prevent a Malpractice Lawsuit? AJR Am J Roentgenol. 2006;187(1):10-5. https://psnet.ahrq.gov/issue/will-saying-im-sorry-prevent-malpractice-lawsuit In the context of a malpractice lawsuit filed after a communicati…

4753. Safety in Radiology | PSNet
      psnet.ahrq.gov/perspective/safety-radiology
      October 01, 2013 - sufficient for accurate diagnoses and the guidance of interventional procedures.( 15 ) Moreover, communicating

4754. Acute Respiratory Arrest in Pregnancy | PSNet
      psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
      August 15, 2018 - Acute Respiratory Arrest in Pregnancy Citation Text: Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

4755. Breathe Easy: Safe Tracheostomy Management | PSNet
      psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
      June 07, 2023 - Breathe Easy: Safe Tracheostomy Management Citation Text: Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar Bib…

4756. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49677/psn-pdf
      February 01, 2013 - CVC Placement: Speak Now or Do Not Use the Line February 1, 2013 Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line The Case A 48-year-old woman with a history of hypertension, psychiatric illness, and a…

4757. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865984/psn-pdf
      May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. May 29, 2024 Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D- dimer. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…

4758. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49475/psn-pdf
      March 01, 2005 - Techno Trip March 1, 2005 Cook RI. Techno Trip. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/techno-trip The Case A 70-year-old woman was admitted to a community hospital after developing confusion and right-sided weakness. A CT scan of her brain showed an acute subdural hematoma. The hospital arranged a…

4759. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33693/psn-pdf
      February 01, 2010 - The Role of Graduate Medical Education (GME) in Improving Patient Safety February 1, 2010 Baron RB, Vidyarthi A. The Role of Graduate Medical Education (GME) in Improving Patient Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety Perspec…

4760. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33596/psn-pdf
      June 01, 2025 - Failure to Rescue January 29, 2025 Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/failure-rescue Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet primers are regularly reviewed and updated to ensure that they reflect cur…