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psnet.ahrq.gov/node/33656/psn-pdf
September 01, 2007 - In Conversation with...Atul Gawande, MD, MA, MPH
September 1, 2007
In Conversation with..Atul Gawande, MD, MA, MPH. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
Editor's Note: Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School
a…
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psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - Breakage of a PICC Line
April 1, 2009
Dimov V. Breakage of a PICC Line. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/breakage-picc-line
Case Objectives
Appreciate the incidence and consequences of PICC line breakage.
Understand the risk factors for PICC line breakage.
Understand the treatment options in…
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - Pathologic Mistake
Citation Text:
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/node/72834/psn-pdf
March 10, 2021 - Approach to Improving Patient Safety: Communication
March 10, 2021
Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet
[internet]. 2021.
https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
Introduction
Each one of the countless necessa…
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psnet.ahrq.gov/node/49679/psn-pdf
March 01, 2013 - The Unfamiliar Catheter
March 1, 2013
Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/unfamiliar-catheter
The Case
A 28-year-old woman, 20 months post–bilateral lung transplant, presented to the emergency department
with sudden onset of severe shortness of breath…
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - The Result Stopped Here
June 1, 2004
Astion ML. The Result Stopped Here. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/result-stopped-here
The Case
A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital
for continued wound care and intravenous (IV) antib…
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psnet.ahrq.gov/web-mm/no-bp-during-nibp
March 01, 2011 - No BP During NIBP
Citation Text:
Görges M, Ansermino MJ. No BP During NIBP. 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/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
August 21, 2007 - SPOTLIGHT CASE
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
Citation Text:
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…
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psnet.ahrq.gov/node/49754/psn-pdf
February 01, 2016 - Picking Up the Cause of the Stroke
February 1, 2016
Chopra V. Picking Up the Cause of the Stroke. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/picking-cause-stroke
The Case
A 62-year-old man with poorly controlled diabetes was transferred to a tertiary care center from a
community hospital for management…
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psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
August 01, 2017 - And most of today's claims data are focused on the inpatient stay, but length of stay has decreased a
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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - correlated with pneumonia severity. 13,14,15 Recognition of this association, as well as tachypnea and decreased
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psnet.ahrq.gov/perspective/safety-and-medical-education
December 01, 2013 - by two noted patient safety experts raised concern that further restriction of duty hours has led to decreased
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psnet.ahrq.gov/node/837959/psn-pdf
August 31, 2022 - Recognition of latex allergy as an important problem led to many practice improvements and a
decreased
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psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
January 01, 2024 - correlated with pneumonia
severity.13,14,15
– Recognition of this association, as well as tachypnea and decreased
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - correlated with pneumonia severity.13,14,15 Recognition of this association, as
well as tachypnea and decreased
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - Additionally, the rate of postpartum complications in Medicaid patients has decreased
significantly.
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - In Conversation With… Andrew Gettinger, MD
September 1, 2017
In Conversation With… Andrew Gettinger, MD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
Editor's note: Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the
Office of Cli…
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psnet.ahrq.gov/node/33746/psn-pdf
March 01, 2013 - In Conversation With… David M. Gaba, MD
March 1, 2013
In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of
Medicine. An international leade…
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psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
August 21, 2005 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism.
Citation Text:
Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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