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psnet.ahrq.gov/node/33671/psn-pdf
July 01, 2008 - The Soil, Not the Seed: The Real Problem with Root
Cause Analysis
July 1, 2008
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause Analysis. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
Perspective
Throughout most of his life, …
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psnet.ahrq.gov/node/33598/psn-pdf
June 15, 2024 - Falls
June 15, 2024
Falls. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/falls
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Background
Falls are a common …
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psnet.ahrq.gov/node/33563/psn-pdf
September 16, 2024 - Culture of Safety
September 16, 2024
Culture of Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/culture-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
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psnet.ahrq.gov/primer/teamwork-training
September 15, 2024 - Teamwork Training
Citation Text:
Teamwork Training. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Dow…
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psnet.ahrq.gov/node/866992/psn-pdf
May 29, 2024 - Harm Reduction Strategies to Improve Safety for People
Who Use Substances
October 30, 2024
Salisbury-Afshar E, Gale B, Mossburg S. Harm Reduction Strategies to Improve Safety for People Who
Use Substances . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-w…
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psnet.ahrq.gov/node/33742/psn-pdf
December 01, 2012 - In Conversation With… Sharon K. Inouye, MD, MPH
December 1, 2012
In Conversation With… Sharon K. Inouye, MD, MPH. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
Editor's note: Sharon K. Inouye, MD, MPH, one of the world's leaders in geriatrics research and
innovatio…
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psnet.ahrq.gov/node/863308/psn-pdf
February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in
Death During Endoscopy
February 28, 2024
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
The Case
A…
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psnet.ahrq.gov/node/49861/psn-pdf
May 01, 2019 - Updates in the Management of High-Risk Pulmonary
Embolism
May 1, 2019
Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
Case Objectives
Review common risk factors, typical present…
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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/49684/psn-pdf
May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical
Error
May 1, 2013
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet].
2013.
https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
Case Objectives
Appreciate that chemotherapy a…
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psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
October 30, 2024 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission
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Save to your library
Print
Download PDF
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C…
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse
Outcomes
July 8, 2022
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
The Cases
Case 1: A 64-year-old man came in for a routine bron…
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psnet.ahrq.gov/node/49478/psn-pdf
April 01, 2005 - Compare and Contrast
April 1, 2005
Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/compare-and-contrast
Case Objectives
Define contrast nephropathy (CN)
List risk factors for CN
Implement pharmacologic strategies for CN prophylaxis
Follow an algorithm for CN risk …
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psnet.ahrq.gov/node/49675/psn-pdf
February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to
Significant Complications
February 1, 2013
Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet
[internet]. 2013.
https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…
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psnet.ahrq.gov/web-mm/emergent-triage-miss
March 06, 2015 - Emergent Triage Miss
Citation Text:
Travers D. Emergent Triage Miss. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the
Senior Clinical Data Analyst at Atrium Health, and Rhonda
Dickman, MSN, RN, CPHQ, the Director of the Tennessee
Hospital Association PSO
January 12, 2022
In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and
Rhonda…
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - But See the Patient First
January 29, 2021
Sinigayan VR. But See the Patient First. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/see-patient-first
The Case
A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief
complaint of fever. Five days previously, he …
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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/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - SPOTLIGHT CASE
Unexplained Apnea Under Anesthesia
Citation Text:
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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