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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39194/psn-pdf
    May 27, 2011 - Disclosing harmful pathology errors to patients. May 27, 2011 Dintzis SM, Gallagher TH. Disclosing harmful pathology errors to patients. Am J Clin Pathol. 2009;131(4):463-5. doi:10.1309/AJCPIO5SHDOD6URI. https://psnet.ahrq.gov/issue/disclosing-harmful-pathology-errors-patients This commentary considers the role of…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35662/psn-pdf
    June 25, 2010 - Debriefing after critical incidents for anaesthetic trainees. June 25, 2010 Tan H. Debriefing after critical incidents for anaesthetic trainees. Anaesth Intensive Care. 2005;33(6):768- 72. https://psnet.ahrq.gov/issue/debriefing-after-critical-incidents-anaesthetic-trainees The author surveyed Australian anesthesi…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49741/psn-pdf
    September 01, 2015 - Abdominal Pain in Early Pregnancy September 1, 2015 Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy Case Objectives Recognize when nausea and vomiting in pregnancy is abnormal. Identify the most common causes of non-obstetric a…
  4. psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
    October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue Citation Text: Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Cit…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36139/psn-pdf
    September 29, 2010 - Trends influencing the cost of care and patient safety. September 29, 2010 Clark R. Trends influencing the cost of care and patient safety. Decision-making in five key areas can improve clinical and economic performance. Health management technology. 2006;27(7):18, 20-1. https://psnet.ahrq.gov/issue/trends-influenc…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42983/psn-pdf
    June 27, 2018 - Medication reconciliation: getting started with IT. June 27, 2018 Lefeber J https://psnet.ahrq.gov/issue/medication-reconciliation-getting-started-it This article reveals the experience of a critical access hospital that used medication reconciliation to expand electronic health record adoption efforts. The author…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36131/psn-pdf
    September 29, 2010 - Emergent CSCW systems: the resolution and bandwidth of workplaces. September 29, 2010 Xiao Y, Seagull J. Emergent CSCW systems: the resolution and bandwidth of workplaces. Int J Med Inform. 2007;76 Suppl 1:S261-6. https://psnet.ahrq.gov/issue/emergent-cscw-systems-resolution-and-bandwidth-workplaces The authors d…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38520/psn-pdf
    September 19, 2016 - Inpatient suicide in a general hospital. September 19, 2016 Cheng I-C, Hu F-C, Tseng M-CM. Inpatient suicide in a general hospital. Gen Hosp Psychiatry. 2009;31(2):110-5. doi:10.1016/j.genhosppsych.2008.12.008. https://psnet.ahrq.gov/issue/inpatient-suicide-general-hospital Suicide attempts by hospitalized patient…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39562/psn-pdf
    June 02, 2010 - Medical errors recovered by critical care nurses. June 2, 2010 Dykes PC, Rothschild JM, Hurley A. Medical errors recovered by critical care nurses. J Nurs Adm. 2010;40(5):241-6. doi:10.1097/NNA.0b013e3181da408e. https://psnet.ahrq.gov/issue/medical-errors-recovered-critical-care-nurses This survey of critical care…
  10. psnet.ahrq.gov/issue/patient-safety-and-staff-competence-managing-challenging-behavior-based-feedback-former
    October 15, 2016 - Study Patient safety and staff competence in managing challenging behavior based on feedback from former psychiatric patients. Citation Text: Tölli S, Kontio R, Partanen P, et al. Patient safety and staff competence in managing challenging behavior based on feedback from former psychiatr…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49673/psn-pdf
    December 01, 2012 - A Real Heartache December 1, 2012 Polevoi SK. A Real Heartache. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/real-heartache The Case A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The pain began at rest, and it radiated to his back and left axilla. He had…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38138/psn-pdf
    October 22, 2008 - Pharmacists and health information technology: emerging issues in patient safety. October 22, 2008 Fuji KT, Galt KA. Pharmacists and Health Information Technology: Emerging Issues in Patient Safety. HEC Forum. 2008;20(3). doi:10.1007/s10730-008-9075-4. https://psnet.ahrq.gov/issue/pharmacists-and-health-informatio…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34623/psn-pdf
    January 28, 2015 - Australian Commission on Safety and Quality in Health Care. January 28, 2015 Australian Commission for Safety and Quality in Health Care. https://psnet.ahrq.gov/issue/australian-commission-safety-and-quality-health-care Established in January 2006, the Commission leads and coordinates improvements in safety and qu…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36938/psn-pdf
    June 30, 2011 - The cost of pneumonia after acute stroke. June 30, 2011 Katzan IL, Dawson NV, Thomas CL, et al. The cost of pneumonia after acute stroke. Neurology. 2007;68(22). doi:10.1212/01.wnl.0000263187.08969.45. https://psnet.ahrq.gov/issue/cost-pneumonia-after-acute-stroke Neglecting measures to prevent pneumonia after str…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49619/psn-pdf
    February 01, 2011 - Paradoxical Pulse February 1, 2011 Roy CL. Paradoxical Pulse. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/paradoxical-pulse The Case An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful pacemaker placement as an outpatient. The patient was restarted on …
  16. 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…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43492/psn-pdf
    September 03, 2014 - Rethinking hospital restraints. September 3, 2014 Parikh R. The Atlantic. August 18, 2014. https://psnet.ahrq.gov/issue/rethinking-hospital-restraints The inappropriate use of physical restraints on patients is considered a sentinel event. Although restraints may be used to protect patients from harm, this magazin…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45517/psn-pdf
    March 01, 2017 - A lost voice. March 1, 2017 Baker M. Seattle Times. February 10, 2017. https://psnet.ahrq.gov/issue/lost-voice Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patie…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34596/psn-pdf
    February 17, 2009 - Disclosure: what works now and what can work even better (part 3 of 3). February 17, 2009 Chicago, IL: American Society of Healthcare Risk Management;  https://psnet.ahrq.gov/issue/disclosure-what-works-now-and-what-can-work-even-better-part-3-3 A guide for communicating throughout the disclosure process, thi…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35530/psn-pdf
    March 02, 2010 - Health care provider use of private sector internal error- reporting systems. March 2, 2010 Roumm AR, Sciamanna CN, Nash DB. Health care provider use of private sector internal error-reporting systems. Am J Med Qual. 2005;20(6):304-12. https://psnet.ahrq.gov/issue/health-care-provider-use-private-sector-internal-e…

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