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psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
June 01, 2004 - complex cases involving communicating with patients about another health care worker's error can help ensure
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psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
December 08, 2021 - process in place designed to identify non–English-speaking patients in advance of their visits and to ensure
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psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
March 24, 2019 - The team (nurses, physician, pharmacist, respiratory therapist) huddled before the procedure to ensure
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psnet.ahrq.gov/node/851099/psn-pdf
June 28, 2023 - Ensure communication between staff inserting the catheter and staff administering medications
There
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psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
May 26, 2021 - opposed to general internet data, and carefully monitoring them for accuracy, will be important to ensure
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - Suction tubing can be inserted into the ETT to ensure that it is not obstructed, and to rule out an unrecognized
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - Council for Continuing Medical Education (ACCME), the University of California, Davis, Health must ensure
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psnet.ahrq.gov/node/867022/psn-pdf
October 30, 2024 - Council
for Continuing Medical Education (ACCME), the University of California, Davis, Health must ensure
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psnet.ahrq.gov/node/49768/psn-pdf
September 01, 2016 - Pharmacists play a key role in medication reconciliation, education, and postdischarge follow-up to ensure
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - Formal "visiting hours" may need to be relaxed or eliminated to ensure that the family is able to be
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Mother's Milk, but Whose Mother?
Citation Text:
Dougherty D. Mother's Milk, but Whose Mother?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/continuing-education
February 26, 2025 - Continuing Education
What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…
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psnet.ahrq.gov/node/33744/psn-pdf
February 01, 2013 - In Conversation With… Beverley H. Johnson
February 1, 2013
In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient-
and Family-…
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psnet.ahrq.gov/node/49540/psn-pdf
August 21, 2007 - Resuscitation Errors: A Shocking Problem
August 21, 2007
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
Case Objectives
Appreciate that delays in defibrillation can have significant negative effects on sur…
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - Spinal Epidural Abscess
Citation Text:
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - Slow Down: Right Drug, Wrong Formulation
Citation Text:
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. 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/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - Perils in Diagnosing a Stroke
Citation Text:
Schindler JL. Perils in Diagnosing a Stroke. 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/resuscitation-errors-shocking-problem
October 19, 2022 - SPOTLIGHT CASE
Resuscitation Errors: A Shocking Problem
Citation Text:
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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…
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
https…