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psnet.ahrq.gov/node/73099/psn-pdf
March 31, 2021 - Supporting nurses as essential partners in diagnosis.
March 31, 2021
Carr S. ImproveDx. March 2021:8(2)
https://psnet.ahrq.gov/issue/supporting-nurses-essential-partners-diagnosis
Effective diagnosis is enhanced through multidisciplinary team-based efforts. This newsletter article
outlines opportunities inhe…
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psnet.ahrq.gov/node/866841/psn-pdf
September 23, 2024 - System Approaches to Social Determinants of Health
Screening and Intervention Innovation Summary
September 23, 2024
https://psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-
intervention-innovation
Summary
UNC Health is a nonprofit healthcare system of more than 500 clinics and…
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psnet.ahrq.gov/node/49577/psn-pdf
January 01, 2009 - Are Two Insulin Pumps Better Than One?
January 1, 2009
Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
The Case
A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass
graft surge…
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psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - Fumbled Handoff
March 1, 2004
Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/fumbled-handoff
The Case
A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and
chronic renal insufficiency was admitted for an elective sigmoid resect…
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psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
January 01, 2016 - Charcoal Lavage of the Lungs
Citation Text:
Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/node/49469/psn-pdf
December 01, 2004 - Overriding Considerations
December 1, 2004
Holtzman NA. Overriding Considerations. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/overriding-considerations
The Case
Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic
testing for a variety of condition…
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psnet.ahrq.gov/node/33812/psn-pdf
August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS,
PhD
August 1, 2016
In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
Editor's note: Dr. Perea-Pérez is Director de la Escuela de Medicina Legal y For…
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - Sleep Deprivation Leads to Medication Error During
Spinal Epidural Anesthesia
August 30, 2023
Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-…
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - Irrespective of educational level, the quality of nurses' on-the-job training may also play a role in
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - disclose relevant financial relationships with commercial interests related to the subject matter of this educational
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
January 01, 2023 - Garth Utter, MD
o Managing Editor: Meghan Weyrich, MPH
2
Objectives
At the conclusion of this educational
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psnet.ahrq.gov/training-catalog/medical-mistakes-and-what-doctors-can-learn-pilots
July 21, 2025 - Medical Mistakes and What Doctors Can Learn From Pilots
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Organization:
Organization
American Academy of Ophthalmology
Even…
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psnet.ahrq.gov/training-catalog/learning-errors-analysis-medication-error
Learning from Errors: Analysis of a Medication Error
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Organization:
Organization
American Association for Critical-Care Nurses (AACN)
…
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psnet.ahrq.gov/training-catalog/improving-care-transitions-older-adults
Improving Care Transitions of Older Adults
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Organization:
Organization
RCTCLEARN.NET
Event Description: This program focu…
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psnet.ahrq.gov/node/40909/psn-pdf
November 09, 2011 - Handing over patient care: is it just the old broken
telephone game?
November 9, 2011
Zendejas B, Ali SM, Huebner M, et al. Handing over patient care: is it just the old broken telephone game?
J Surg Educ. 2011;68(6):465-71. doi:10.1016/j.jsurg.2011.05.011.
https://psnet.ahrq.gov/issue/handing-over-patient-care-it…
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psnet.ahrq.gov/node/73401/psn-pdf
June 16, 2021 - Second victim: a traumatic experience.
June 16, 2021
Wands B. AANA J. 2021;89(2):168-174.
https://psnet.ahrq.gov/issue/second-victim-traumatic-experience
Healthcare professionals who experience emotional consequences after adverse events are often referred
to as “second victims.” Targeted towards certified registe…
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psnet.ahrq.gov/node/38437/psn-pdf
February 25, 2009 - Beyond "see one, do one, teach one": toward a different
training paradigm.
February 25, 2009
Rodriguez-Paz JM, Kennedy M, Salas E, et al. Beyond "see one, do one, teach one": toward a different
training paradigm. Qual Saf Health Care. 2009;18(1):63-8. doi:10.1136/qshc.2007.023903.
https://psnet.ahrq.gov/issue/beyo…
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psnet.ahrq.gov/node/44553/psn-pdf
October 07, 2015 - A medical detective story: why doctors make diagnostic
errors.
October 7, 2015
Landro L. Wall Street Journal. September 26, 2015.
https://psnet.ahrq.gov/issue/medical-detective-story-why-doctors-make-diagnostic-errors
In light of the recent IOM report on improving diagnosis, this newspaper article features an inte…
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psnet.ahrq.gov/node/40868/psn-pdf
October 19, 2011 - Simulation to enhance patient safety: why aren't we there
yet?
October 19, 2011
Aggarwal R, Darzi A. Simulation to enhance patient safety: why aren't we there yet? Chest.
2011;140(4):854-858. doi:10.1378/chest.11-0728.
https://psnet.ahrq.gov/issue/simulation-enhance-patient-safety-why-arent-we-there-yet
Discussin…
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psnet.ahrq.gov/node/46855/psn-pdf
February 21, 2018 - Leadership and vision for a culture of safety.
February 21, 2018
Gandhi TK. NEJM Catalyst. February 8, 2018.
https://psnet.ahrq.gov/issue/leadership-and-vision-culture-safety
Leadership has an important role in establishing a culture of safety in health care organizations. This
commentary describes key skills requ…