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psnet.ahrq.gov/primer/disclosure-errors
September 15, 2024 - Disclosure of Errors
Citation Text:
Disclosure of Errors. 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/node/33568/psn-pdf
June 15, 2024 - Root Cause Analysis
June 15, 2024
Root Cause Analysis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/root-cause-analysis
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…
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psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
March 01, 2009 - In Conversation with...Dean Schillinger, MD
March 22, 2009
Also Read an Essay
Citation Text:
In Conversation with..Dean Schillinger, MD. PSNet [internet]. 2009.In Conversation with...Dean Schillinger, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - volume prior to catheterization ( 13 ); maintaining the drainage bag below the level of the bladder; and ensuring
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring … waits and harmful delays for those who receive and those who give care Providing effective access, ensuring
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psnet.ahrq.gov/node/72613/psn-pdf
December 22, 2020 - biggest AE is pain and while pain may be normal, we need to change the
perspective that focuses on ensuring
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - additional results, revisions to innovation description, considerations for planning and development, and
ensuring
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - postoperative management strategies to address intraoperative durotomy and CSF leaks, and approaches to ensuring
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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - Thus, the responsibility in this case for ensuring that the patient receives SSI and VTE prophylaxis
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - What Happened on Telemetry?
April 1, 2019
Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/what-happened-telemetry
Case Objectives
Describe current hospital practices for continuous telemetry monitoring.
Appreciate key recommendations from the Update to Practice…
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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Hidden Mystery
March 1, 2005
Brunette DD. Hidden Mystery. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hidden-mystery
Case Objectives
Appreciate the challenges of caring for morbidly obese patients.
List specific interventions that can be implemented when caring for obese patients.
Develop a rational ap…
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psnet.ahrq.gov/node/49765/psn-pdf
August 21, 2016 - Cognitive Overload in the ICU
August 21, 2016
Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/cognitive-overload-icu
Case Objectives
Identify the role of cognitive overload—especially interruptions—in compromising quality of care and
patient safety.
List…
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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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/865412/psn-pdf
March 27, 2024 - Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
March 27, 2024
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a
Psychiatric Presentation. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatmen…
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psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - In Conversation With… Richard Kronick, PhD
February 1, 2014
In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since
August 2013 …
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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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/33837/psn-pdf
July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD
July 1, 2017
In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
Editor's note: Michelle Mello is Professor of Law at Stanford Law School and Professor of Healt…
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …