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psnet.ahrq.gov/node/60376/psn-pdf
July 30, 2020 - COVID-19: Team and Human Factors to Improve Safety
July 30, 2020
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
Background
The rapid transmission of COVID-19 has resulted in an international pandem…
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psnet.ahrq.gov/web-mm/missing-suction-tip
January 01, 2006 - SPOTLIGHT CASE
The Missing Suction Tip
Citation Text:
Thomas EJ, Moore FA. The Missing Suction Tip. 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/late-anemia-following-rh-disease-newborn
June 17, 2010 - Late Anemia Following Rh Disease in a Newborn
Citation Text:
Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. 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/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
May 01, 2017 - Wrong Turn through Colon: Misplaced PEG
Citation Text:
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - Treatment Challenges After Discharge
November 1, 2010
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
Case Objectives
Understand types and frequencies of adverse events occurring between patient discharge from the
hospital …
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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - Haste Makes Care Unsafe
Citation Text:
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/72618/psn-pdf
December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral
Changes Towards Medical Decisions that Improve Care
Value and Quality of Care
December 23, 2020
https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-
medical-decisions
Summary
Nudges are a change in the way choices ar…
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - Discontinued Medications: Are They Really Discontinued?
Citation Text:
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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…
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - CYP450 Drugs: Expect the Unexpected
Citation Text:
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. 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/node/49627/psn-pdf
June 01, 2011 - The ECG Is Not Normal
June 1, 2011
Zuger A. The ECG Is Not Normal. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/ecg-not-normal
Case Objectives
State how frequently physicians care for family or relatives.
Describe the risks associated with caring for family members or relatives.
Appreciate some of the s…
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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/node/33883/psn-pdf
July 01, 2019 - In Conversation With… Suchi Saria, PhD
July 1, 2019
In Conversation With… Suchi Saria, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
Editor's note: Dr. Saria is the John C. Malone Assistant Professor of computer science, statistics, and
health policy at Johns Hopkins …
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psnet.ahrq.gov/node/865984/psn-pdf
May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain
with Elevated D-dimer.
May 29, 2024
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-
dimer. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…
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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - Diffusion of Responsibility Leads to Danger
Citation Text:
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/49594/psn-pdf
December 01, 2009 - Standard Deviations
December 1, 2009
Sabin JE. Standard Deviations. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/standard-deviations
Case Objectives
Understand the safety risks associated with patients being discharged against medical advice
(AMA).
Recognize safety risks associated with being part of a …
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psnet.ahrq.gov/node/60173/psn-pdf
March 30, 2020 - In Conversation With... Ann Gaffey, RN, MSN, CPHRM and
Bruce Spurlock, MD
March 30, 2020
In Conversation With.. Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
Editor’s note: Ann D. Gaffey, RN, …
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psnet.ahrq.gov/node/49446/psn-pdf
August 30, 2021 - Too Tight Control
May 1, 2004
Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/too-tight-control
Case Objectives
Appreciate the advantages and potential complications of intensive insulin therapy in the hospitalized
patient
List hospital-based safeguards available to…