- 
                                        
psnet.ahrq.gov/node/49633/psn-pdf
September 01, 2011 - The Safety and Quality of Long Term Care
September 1, 2011
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
Case Objectives
Identify commonly reported adverse events in long-term care.
Identify two to three challenges… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - The Consequences of Miscommunication Regarding a
Possible Artifact
June 30, 2021
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
Disclosure of Relevant Financial Relationships… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. 
 
 
 
 
 Citation Text: 
 Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. 
 
 
 
 
 Citation Text: 
 Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/33839/psn-pdf
August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
Editor's note:  Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of
Northwester… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
May 11, 2019 - SPOTLIGHT CASE
         
 The Consequences of Miscommunication Regarding a Possible Artifact 
 
 
 
 
 Citation Text: 
 Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/33849/psn-pdf
January 01, 2018 - In Conversation With… Robert Hirschtick, MD
January 1, 2018
In Conversation With… Robert Hirschtick, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
Editor's note:  Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author
of a numbe… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/846769/psn-pdf
March 29, 2023 - Missed Diagnosis of Addison’s Disease in Adolescent
Presenting with Fatigue.
March 29, 2023
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
The C… 
                                     
                                                                    - 
                                        
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. … 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
November 25, 2020 - Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation 
 
 
 
 
 Citation Text: 
 Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. 
… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/periodic-issue/periodic-issue-469
December 31, 2024 - January 8, 2025 Weekly Issue 
 
            PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
            Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
            safety literature, news, conferences, reports… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/print/pdf/node/867461
January 31, 2024 - PSNet
			Curated Library
AHRQ: Agency for Healthcare Research and Quality
Patient and Family Engagement in Long
Term Care
Curated Library
Foundations
Long-term Care and Patient Safety
Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA | April, 10 2024
A large and growing number of Americans require care in skilled nursin… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - Spinal Epidural Abscess 
 
 
 
 
 Citation Text: 
 Lu Y, Salvador D. Spinal Epidural Abscess. 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 tag… 
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
June 24, 2010 - an annual basis, approximately 94,000 patients develop serious MRSA infections resulting in 18,650 deaths
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - There were many patient deaths in younger individuals who came in walking, talking, and then deteriorated … And sometimes there were multiple deaths in a day, which really took its toll.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - There were many patient deaths in younger individuals who came in walking, talking, and then deteriorated … And sometimes there were multiple deaths in a day, which really took its toll.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - January 2, 2017 
 
 
 
 
 
 
 
 Effects of nurse staffing and nurse education on patient deaths in hospitals