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  1. Missed Patient Assignment: Is Anyone There? | PSNet

    psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
    September 01, 2017 - The concern for this neglected patient and the potential for similar events in the future led to a root

  2. To Transfer or Not to Transfer | PSNet

    psnet.ahrq.gov/web-mm/transfer-or-not-transfer
    November 23, 2016 - Because of repeated AICD firings and concern for a heart attack, he was taken in the ambulance.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33573/psn-pdf
    March 15, 2025 - Disruptive and Unprofessional Behavior March 15, 2025 Disruptive and Unprofessional Behavior. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current resear…

  4. Medical Scribes and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
    August 01, 2019 - between providers, and reducing documentation errors.( 22 ) However, scribe skeptics have expressed concern … The concern with that method was that it would incentivize longer and more complex notes, which was not

  5. Engaging Seriously Ill Older Patients in Advance Care Planning | PSNet

    psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
    December 22, 2018 - SPOTLIGHT CASE Engaging Seriously Ill Older Patients in Advance Care Planning Citation Text: Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. …

  6. The Hidden Danger of Unseen Intravenous Catheters | PSNet

    psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
    October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters Citation Text: Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google S…

  7. Harm From Alarm Fatigue | PSNet

    psnet.ahrq.gov/web-mm/harm-alarm-fatigue
    February 14, 2018 - SPOTLIGHT CASE Harm From Alarm Fatigue Citation Text: Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49779/psn-pdf
    January 01, 2017 - The Empty Bag December 1, 2016 Vincent C. The Empty Bag. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/empty-bag The Case A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a hip fracture after a fall at a nursing home. During the hospitalization, her kidne…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74251/psn-pdf
    January 26, 2022 - In this case, review of the numerous failed attempts at cannulation should have raised concern about

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33885/psn-pdf
    August 01, 2019 - The concern with that method was that it would incentivize longer and more complex notes, which was

  11. Safeguarding Diagnostic Testing at the Point of Care | PSNet

    psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
    September 30, 2011 - Safeguarding Diagnostic Testing at the Point of Care Citation Text: Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838855/psn-pdf
    October 27, 2022 - False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. October 27, 2022 Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/false-assumptions-resul…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33746/psn-pdf
    March 01, 2013 - In Conversation With… David M. Gaba, MD March 1, 2013 In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of Medicine. An international leade…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33865/psn-pdf
    September 01, 2018 - In Conversation With… Rebecca Lawton, PhD September 1, 2018 In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd Editor's note: Rebecca Lawton, a Professor in the Psychology of Healthcare at the University of Leeds, is a health psycho…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33674/psn-pdf
    February 01, 2009 - My concern is that, for the policy to be appropriate and just, the events really do need to be preventable

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33805/psn-pdf
    April 01, 2016 - The third dimension is our ongoing attention and real concern about professionalism and professional

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33754/psn-pdf
    September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD September 1, 2013 In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33875/psn-pdf
    March 01, 2019 - I don't see that as a special concern.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852808/psn-pdf
    August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication Breakdown. August 30, 2023 Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown Disclosure of Relevant Financial Relationship…

  20. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
    January 01, 2023 - Spotlight Spotlight Prolonged DKA in Pregnancy: A Case of Communication Breakdown Source and Credits • This presentation is based on the August 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarah Marshall, MD and Nina M. …
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