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psnet.ahrq.gov/node/860015/psn-pdf
September 01, 2024 - Retained Surgical Items: Definition and Epidemiology.
January 4, 2024
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
Background
Prudent medical practice and federal and state laws r…
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psnet.ahrq.gov/node/49817/psn-pdf
January 01, 2018 - Slow Down: Right Drug, Wrong Formulation
January 1, 2018
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
The Case
A 65-year-old man presented to his primary care clinic for follow-up after a recent hospitaliz…
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psnet.ahrq.gov/web-mm/suicidal-man-gun
May 01, 2005 - Suicidal Man With Gun
Citation Text:
Simon RI. Suicidal Man With Gun. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
February 24, 2021 - SPOTLIGHT CASE
Is the "Surgical Personality" a Threat to Patient Safety?
Citation Text:
Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - The Second Victim Phenomenon: A Harsh Reality of
Health Care Professions
May 1, 2011
Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [internet].
2011.
https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
Perspective
The Instit…
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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - What Have We Learned About Safe Inpatient Handovers?
March 1, 2011
Kripalani S. What Have We Learned About Safe Inpatient Handovers? PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
Perspective
The care of hospitalized patients is marked by numerous tra…
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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool
Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012
View more articles from the same authors.
Citation Text:
Joseph A, Malone EB. The Physical Environment: An Often Unc…
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psnet.ahrq.gov/node/60609/psn-pdf
June 24, 2020 - When the Indications for Drug Administration Blur
June 24, 2020
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accre…
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psnet.ahrq.gov/node/846127/psn-pdf
March 15, 2023 - Sepsis Resulting from Delays in Treatment and
Miscommunication among Specialists
March 15, 2023
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-
spec…
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psnet.ahrq.gov/node/49613/psn-pdf
November 01, 2010 - Mother's Milk, but Whose Mother?
November 1, 2010
Dougherty D. Mother's Milk, but Whose Mother? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
The Case
A 2-month-old otherwise healthy infant was admitted to the hospital to rule out sepsis. The infant had been
exclusively breastfed…
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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - Silent Pain in the Neck
February 1, 2011
Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/silent-pain-neck
The Case
A 60-year-old man with no significant past medical history underwent an elective anterior cervical
discectomy for persistent right arm weakness due to cervi…
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psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - Mistaken Identity
Citation Text:
Hall LW. Mistaken Identity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
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…
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psnet.ahrq.gov/node/49426/psn-pdf
November 01, 2003 - Don't Push
November 1, 2003
Meltzer HY. Don't Push. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dont-push
The Case
A 37-year-old HIV-positive woman was brought to the emergency room by her family because she had
exhibited altered mentation for 3 days. The patient had been diagnosed with HIV infection 3 …
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psnet.ahrq.gov/node/60652/psn-pdf
June 29, 2020 - In Conversation With... Anna Legreid Dopp, Pharm. D
June 29, 2020
In Conversation With.. Anna Legreid Dopp, Pharm. D. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
Editor’s note: Anna Legreid Dopp, Pharm. D is the Senior Director of Clinical Guidelines and Quality…
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psnet.ahrq.gov/node/49535/psn-pdf
May 01, 2007 - Production Pressures
May 1, 2007
Carayon P. Production Pressures. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/production-pressures
The Case
A 65-year-old man with bipolar disorder was scheduled for maintenance electroconvulsive therapy (ECT), a
procedure he had received dozens of times before. These pro…
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psnet.ahrq.gov/node/49662/psn-pdf
August 01, 2012 - Wrong Turn through Colon: Misplaced PEG
August 1, 2012
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
The Case
An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…
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psnet.ahrq.gov/node/33886/psn-pdf
August 01, 2019 - Medical Scribes and Patient Safety
August 1, 2019
Woodcock D, Bergstrom R. Medical Scribes and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
Perspective
Scribes have supported physicians for thousands of years.(1) However, little is known about how to…
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psnet.ahrq.gov/node/50929/psn-pdf
February 26, 2020 - Discharged with IV antibiotics: When issues arise, who
manages the complications?
February 26, 2020
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the
complications? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-…
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psnet.ahrq.gov/node/49462/psn-pdf
October 01, 2004 - Thin Air
October 1, 2004
Gaba DM. Thin Air. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/thin-air
Case Objectives
Identify the gas-specific non-interchangeable connectors used for bulk gas supply outlets in
hospitals.
Define forcing function, both in engineered safety devices and in human procedures.
R…
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - 40 of K
Citation Text:
Lesar TS. 40 of K. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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