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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - Management of Cardiac Arrest in Unconventional
Locations.
May 16, 2022
Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
The Case
Case #1: An 80-year-old man with history of Parkins…
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
Editor's note: The topic of patient safety in long-term care facilities has not received the attent…
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
…
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psnet.ahrq.gov/node/49708/psn-pdf
May 01, 2014 - Medication Reconciliation With a Twist (or Dare We Say, a
Patch?)
May 1, 2014
Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
Case Objectives
Appreciate that medication discrepanc…
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psnet.ahrq.gov/node/33766/psn-pdf
May 01, 2014 - In Conversation With… Didier Pittet, MD, MS
May 1, 2014
In Conversation With… Didier Pittet, MD, MS. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
Editor's note: Didier Pittet, MD, MS, is Professor of Medicine and Director of the Infection Control
Programme and WHO Co…
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - Palliative Care: Comfort vs. Harm
November 1, 2017
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
Case Objectives
Recognize errors may be difficult to identify in palliative care.
State that medication errors and errors in communica…
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
Citation Text:
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - SPOTLIGHT CASE
The Safety and Quality of Long Term Care
Citation Text:
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Goog…
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - SPOTLIGHT CASE
Prolonged DKA in Pregnancy: A Case of Communication Breakdown.
Citation Text:
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
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psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
Citation Text:
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.In Conversation with...Patrick S. Romano, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/issue/implementation-custom-alert-prevent-medication-timing-errors-associated-computerized
April 25, 2016 - Study
Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry.
Citation Text:
Idemoto LM, Williams BL, Ching JM, et al. Implementation of a custom alert to prevent medication-timing errors associated with computerized presc…
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psnet.ahrq.gov/issue/interprofessional-learning-multidisciplinary-healthcare-teams-associated-reduced-patient
April 10, 2024 - Review
Interprofessional learning in multidisciplinary healthcare teams is associated with reduced patient mortality: a quantitative systematic review and meta-analysis.
Citation Text:
Webster CS, Coomber T, Liu S, et al. Interprofessional learning in multidisciplinary healthcare teams i…
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psnet.ahrq.gov/issue/systematic-review-psychological-literature-interruption-and-its-patient-safety-implications
September 24, 2016 - Review
Classic
A systematic review of the psychological literature on interruption and its patient safety implications.
Citation Text:
Li SYW, Magrabi F, Coiera E. A systematic review of the psychological literature on interruption and its patient safety implica…
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psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic-complication
November 16, 2022 - Study
Classic
Accident analysis of large-scale technological disasters applied to an anaesthetic complication.
Citation Text:
Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Can J An…
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psnet.ahrq.gov/issue/impact-drug-shortage-medication-errors-and-clinical-outcomes-pediatric-intensive-care-unit
November 16, 2022 - Study
Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.
Citation Text:
Hughes KM, Goswami ES, Morris JL. Impact of a Drug Shortage on Medication Errors and Clinical Outcomes in the Pediatric Intensive Care Unit. J Pediatr Pharmacol…
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psnet.ahrq.gov/issue/randomized-trial-improve-prescribing-safety-ambulatory-elderly-patients
March 10, 2011 - Study
Randomized trial to improve prescribing safety in ambulatory elderly patients.
Citation Text:
Raebel MA, Charles J, Dugan J, et al. Randomized trial to improve prescribing safety in ambulatory elderly patients. J Am Geriatr Soc. 2007;55(7):977-85.
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psnet.ahrq.gov/issue/safer-prescribing-and-care-elderly-space-cluster-randomised-controlled-trial-general-practice
November 18, 2020 - Study
Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice.
Citation Text:
Wallis KA, Elley CR, Moyes SA, et al. Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice. BJGP Open. …
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psnet.ahrq.gov/issue/cler-report-findings-2021-subprotocol-operative-and-procedural-areas
October 18, 2017 - Book/Report
CLER Report of Findings 2021: Subprotocol for Operative and Procedural Areas.
Citation Text:
CLER Report of Findings 2021: Subprotocol for Operative and Procedural Areas. Kuhn CM, Newton RC, Damewood MD, et al, on behalf of the CLER Evaluation Committee, the CLER Operative an…
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psnet.ahrq.gov/issue/work-hour-restrictions-ethical-dilemma-residents
April 24, 2018 - Study
Work-hour restrictions as an ethical dilemma for residents.
Citation Text:
Carpenter RO, Austin MT, Tarpley JL, et al. Work-hour restrictions as an ethical dilemma for residents. Am J Surg. 2006;191(4):527-32.
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