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5541. In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - Across healthcare, surveys reveal workforce concern that healthcare workers are unable to provide safe

5542. In Conversation With... Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN | PSNet
      psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-popejoy-phd-rn-faan
      October 28, 2020 - In Conversation With... Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN October 28, 2020  Also Read the Essay Citation Text: In Conversation With.. Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN. PSNet [internet]. 2020.In C…

5543. Beyond the Pandemic: Creating Total Systems Safety | PSNet
      psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
      August 30, 2023 - Across healthcare, surveys reveal workforce concern that healthcare workers are unable to provide safe

5544. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please | PSNet
      psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
      September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please Teryl K. Nuckols, MD, MSHS | September 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Nuckols TK. Incident Reporting: More Attention to the …

5545. In Conversation With…Kaveh G. Shojania, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
      September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD September 1, 2011  Also Read an Essay Citation Text: In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

5546. What Have We Learned About Safe Inpatient Handovers? | PSNet
      psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
      March 01, 2011 - maybe there will be cuts somewhere else that impact residency education or patient safety, which is a concern

5547. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33644/psn-pdf
      December 01, 2006 - Establishing a Safety Culture: Thinking Small December 1, 2006 Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small Perspective Safety cultures are the holy grail in any risky industry. Like all holy grails, th…

5548. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49824/psn-pdf
      March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay March 1, 2018 O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay The Case A 35-year-old woman with no prior cardiac history calle…

5549. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33848/psn-pdf
      December 01, 2017 - The Evolution of Patient Safety in Surgery December 1, 2017 Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/evolution-patient-safety-surgery Perspective In 1979, 20 years before the Institute of Medicine's To Err Is Human report (1) catalyzed the cr…

5550. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49409/psn-pdf
      July 01, 2003 - Feeling No Pain July 1, 2003 Bogner MS. Feeling No Pain. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/feeling-no-pain The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…

5551. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49514/psn-pdf
      July 01, 2006 - One ACE Too Many July 1, 2006 Juurlink DN. One ACE Too Many. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/one-ace-too-many The Case A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure presented to the emergency department (ED) with chest pain. An acut…

5552. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33747/psn-pdf
      March 01, 2013 - The Literature on Health Care Simulation Education: What Does It Show? March 1, 2013 Cook DA. The Literature on Health Care Simulation Education: What Does It Show? PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show Perspective The education o…

5553. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49842/psn-pdf
      September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…

5554. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49510/psn-pdf
      May 01, 2006 - Cups of Error May 1, 2006 Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/cups-error The Case An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered from dementia, he remained alert and oriented with only mild short-term memory…

5555. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49577/psn-pdf
      January 01, 2009 - Are Two Insulin Pumps Better Than One? January 1, 2009 Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one The Case A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass graft surge…

5556. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60548/psn-pdf
      May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020 In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food…

5557. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33615/psn-pdf
      June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD June 1, 2005 In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd Editor's Note: Peter J. Pronovost, MD, PhD, is Medical Director of the Johns Hopkins Center for Innova…

5558. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49469/psn-pdf
      December 01, 2004 - Overriding Considerations December 1, 2004 Holtzman NA. Overriding Considerations. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/overriding-considerations The Case Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic testing for a variety of condition…

5559. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49839/psn-pdf
      August 01, 2018 - Mixup Beyond the Medication Label August 1, 2018 Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label The Case An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another hospi…

5560. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843736/psn-pdf
      February 01, 2023 - Saved by ECMO February 1, 2023 Weiss NA. Saved by ECMO . PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/saved-ecmo The Case A 27-year-old pregnant woman was admitted at an estimated gestational age (EGA) of 29 weeks for increased shortness of breath. She was diagnosed with severe pulmonary arterial hyperte…