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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - Considering the liability that a hospital may incur, cleansing or disposing of this equipment may result
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psnet.ahrq.gov/node/49560/psn-pdf
April 01, 2008 - include taking steps to ensure that the goals of care are
communicated across settings of care and considering
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psnet.ahrq.gov/node/49596/psn-pdf
December 01, 2009 - This patient's experience illustrates several key points for those considering or advising others about
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Answers to these questions provide a framework for considering solutions
based on patterns of behavior
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psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - In
considering this question, it is important to recognize that it is essential that physicians in training
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - leadership, focusing on stronger corrective actions, measuring implementation and impact on outcomes, and considering
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psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
March 23, 2012 - Book/Report
Classic
Serious Reportable Events in Healthcare—2011 Update.
Citation Text:
Serious Reportable Events in Healthcare—2011 Update. Washington DC: National Quality Forum; December 2011.
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psnet.ahrq.gov/issue/another-round-blame-game-paralyzing-criminal-indictment-recklessly-overrides-just-culture
May 02, 2018 - Newspaper/Magazine Article
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
Citation Text:
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture. ISMP Medication Safety Alert! …
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - record and requires that they be completed within 30 days of discharge.( 8 ) This is far too permissive, considering … mandated that all hospitals publicly report care transition measure scores, and two other states are considering
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - mandated that all hospitals publicly report care transition measure scores, and two other states are considering … record and requires that they be completed within 30 days of discharge.( 8 ) This is far too permissive, considering
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psnet.ahrq.gov/node/44021/psn-pdf
March 25, 2015 - Quick Safety.
March 25, 2015
Oakbrook Terrace, IL: The Joint Commission.
https://psnet.ahrq.gov/issue/quick-safety
This newsletter provides brief introductions to specific patient safety concerns or incidents and includes
recommendations to consider for improvement.
https://psnet.ahrq.gov/issue/quick-safety
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psnet.ahrq.gov/node/35065/psn-pdf
October 05, 2005 - Why the need to reduce medical errors is not obvious.
October 5, 2005
Buetow S.
https://psnet.ahrq.gov/issue/why-need-reduce-medical-errors-not-obvious
The author considers whether medical errors are always problematic and asserts a distinction between
desirable and undesirable errors.
https://psnet.ahrq.gov/issu…
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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.
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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…
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psnet.ahrq.gov/node/35370/psn-pdf
November 28, 2016 - Going to the hospital? Don't forget to pack a nurse.
November 28, 2016
Tugend A.
https://psnet.ahrq.gov/issue/going-hospital-dont-forget-pack-nurse
This article discusses concerns about nurse shortages and why a patient or family might consider retaining
a private-duty nurse for a hospital stay.
https://psnet.ahr…
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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…
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psnet.ahrq.gov/node/36673/psn-pdf
January 18, 2011 - Patient safety: honoring advanced directives.
January 18, 2011
Tice MA. Patient safety: honoring advanced directives. Home Healthc Nurse. 2007;25(2):79-81.
https://psnet.ahrq.gov/issue/patient-safety-honoring-advanced-directives
The author discusses why failure to follow an advance directive should be considered a …
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psnet.ahrq.gov/node/36125/psn-pdf
April 03, 2012 - Safe handover in psychiatry: is it time to set standards?
April 3, 2012
Gulati G.
https://psnet.ahrq.gov/issue/safe-handover-psychiatry-it-time-set-standards
The investigators asked National Health Service consultants and house officers what they would
consider an ideal handoff in psychiatric care. They found that…
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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 …
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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…