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psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
July 19, 2023 - Acute Care Admission of the Behavioral Health Patient
Citation Text:
Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
April 24, 2024 - Right Electrocardiogram, Wrong Patient
Citation Text:
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - Primary Workaround, Secondary Complication
Citation Text:
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. 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/web-mm/patient-safety-and-adherence-self-administered-medications
September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications
Citation Text:
Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011…
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psnet.ahrq.gov/node/49417/psn-pdf
October 01, 2003 - Lost in the Black Hole
October 1, 2003
Wachter R. Lost in the Black Hole. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lost-black-hole
The Case
A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis.
She had a remote history of gonorrhea, no environmental exposu…
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - Low on the Totem Pole
December 1, 2005
Wachter R. Low on the Totem Pole. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/low-totem-pole
Case Objectives
Understand the concept of authority gradient
List steps that can be taken to increase communication across an authority gradient
Consider the current cultu…
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - New Patient Mistakenly Checked in as Another
Citation Text:
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. 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/web-mm/transfusion-slip
June 14, 2011 - Transfusion "Slip"
Citation Text:
Kaplan HS. Transfusion "Slip". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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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/49403/psn-pdf
June 01, 2003 - Missed Appendicitis
June 1, 2003
Adams JG. Missed Appendicitis. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missed-appendicitis
Case Objectives
Appreciate the variable presentations of appendicitis
List complications of missed appendicitis
Understand the advantages and disadvantages of CT in diagnosing…
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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - Bloody BP Cuff
Citation Text:
Madan AK. Bloody BP Cuff. 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/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/49512/psn-pdf
May 01, 2006 - Right? Left? Neither!
May 1, 2006
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-left-neither
Case Objectives
Appreciate the role of Reason's Swiss Cheese Model in medical errors
Understand the process of analyzing a single error
Provide suggestions for …
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psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic
January 12, 2022
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and…
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psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD; Zoe Sousane, BS; Sarah Mossburg, RN, PhD
| February 28, 2024
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psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD | February 28, 2024
Also Read the Essay
Citation Text:
In Conversation With..Stephen Hines, PhD an…
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psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
August 01, 2019 - Medical Scribes and Patient Safety
Deborah Woodcock, MS, MBA; Robby Bergstrom | August 1, 2019
Also Read a Conversation
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Citation Text:
Woodcock D, Bergstrom R. Medical Scribes and Patient Safety. PSNet [internet]. Rockv…
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psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cybersecurity
March 27, 2024 - In Conversation with...Barbara Pelletreau and John Riggi about Cybersecurity
Barbara Pelletreau, RN; John Riggi | March 27, 2024
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Citation Text:
Pelletreau B, Riggi J. In Conversation with..Barbara Pe…
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
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
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Citation Text:
In Conversation With.…
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - Failed Interpretation of Screening Tool: Delayed
Treatment
September 1, 2017
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
The Case
An 88-year-old man present…