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9941. In Conversation With... Jack Westfall, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
      September 28, 2022 - In Conversation With... Jack Westfall, MD, MPH September 28, 2022  Also Read the Essay Citation Text: In Conversation With.. Jack Westfall, MD, MPH. PSNet [internet]. 2022.In Conversation With... Jack Westfall, MD, MPH. PSNet [internet]. Rockville (MD): Agency for…

9942. Inadvertent Use of More Potent Acid Leads to Burn | PSNet
      psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
      November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn Citation Text: Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…

9943. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49460/psn-pdf
      September 01, 2004 - Security Lapse September 1, 2004 Mason D. Security Lapse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/security-lapse The Case A medical student learned that the hospital's radiology image library was accessible throughout the university's computer system, meaning that patient x-rays could be viewed in d…

9944. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49509/psn-pdf
      April 01, 2006 - Insert Omission April 1, 2006 Darney P. Insert Omission. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/insert-omission The Case A multiparous woman presented to the gynecology clinic requesting intrauterine contraceptive (IUC) placement (Figure). She was appropriately counseled on the risks and benefits o…

9945. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49667/psn-pdf
      October 01, 2012 - Looking for Meds in All the Wrong Places October 1, 2012 Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places The Case A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She went to t…

9946. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49692/psn-pdf
      September 01, 2013 - A Picture Speaks 1000 Words September 1, 2013 Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words The Case A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection repair presented with chest p…

9947. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33595/psn-pdf
      December 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety December 15, 2024 Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that th…

9948. Second Victims: Support for Clinicians Involved in Errors and Adverse Events | PSNet
      psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
      December 15, 2024 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events Citation Text: Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cit…

9949. Human Factors Engineering | PSNet
      psnet.ahrq.gov/primer/human-factors-engineering
      December 15, 2024 - Human Factors Engineering Citation Text: Human Factors Engineering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

9950. In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
      December 14, 2022 - Finally, care and information must be delivered to individuals in a manner that is understandable in a cultural

9951. Measuring Patient Safety | PSNet
      psnet.ahrq.gov/perspective/measuring-patient-safety
      December 14, 2022 - Finally, care and information must be delivered to individuals in a manner that is understandable in a cultural

9952. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units | PSNet
      psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
      April 26, 2023 - We were already there, so we didn’t have any cultural barriers to running a safety learning lab predicated

9953. Unseen Perils of Urinary Catheters | PSNet
      psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
      January 31, 2024 - Unseen Perils of Urinary Catheters Citation Text: Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar Bib…

9954. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846975/psn-pdf
      March 28, 2023 - In Conversation with... Christie Allen about Maternal Safety and Perinatal Mental Health March 28, 2023 In Conversation with.. Christie Allen about Maternal Safety and Perinatal Mental Health. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal…

9955. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60542/psn-pdf
      May 27, 2020 - Life-Threatening Infant Overdose of Sodium Chloride May 27, 2020 Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride The Case  An infant with trisomy 21 underwent repair of a…

9956. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33861/psn-pdf
      July 01, 2018 - In Conversation With… Gordon Schiff, MD July 1, 2018 In Conversation With… Gordon Schiff, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-gordon-schiff-md Editor's note: Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, Associate Pr…

9957. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/848754
      January 01, 2025 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Implementation of Patient Safety Projects Curated Library Foundations Leading change: why transformation efforts fail. Kotter JP. Harvard Bus Rev  1995;73(2);59-67. Kotter, a professor at Harvard Business School, outlines the eight stages …

9958. In Conversation With… Maureen Bisognano | PSNet
      psnet.ahrq.gov/perspective/conversation-maureen-bisognano
      February 26, 2025 - In Conversation With… Maureen Bisognano June 1, 2015  Citation Text: In Conversation With… Maureen Bisognano. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: …

9959. In Conversation With… Gordon Schiff, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
      February 26, 2025 - In Conversation With… Gordon Schiff, MD July 1, 2018  Citation Text: In Conversation With… Gordon Schiff, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …

9960. In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
      February 26, 2025 - In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD April 1, 2019  Citation Text: In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…