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  1. psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
    December 01, 2009 - In Conversation with…Gerald B. Hickson, MD December 1, 2009  Also Read an Essay Citation Text: In Conversation with…Gerald B. Hickson, MD . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
  2. psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
    December 01, 2009 - How to Identify and Manage Problem Behaviors Alan H. Rosenstein, MD, MBA; Michelle O'Daniel, MSG, MHA | December 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Rosenstein AH, O'Daniel M. How to Identify and Manage Prob…
  3. psnet.ahrq.gov/issue/changes-medication-safety-indicators-england-throughout-covid-19-pandemic-using-opensafely
    October 19, 2022 - psnet
  4. psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
    August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia Citation Text: Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  5. psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
    April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens Citation Text: Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49519/psn-pdf
    September 01, 2006 - Triple Handoff September 1, 2006 Vidyarthi A. Triple Handoff. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/triple-handoff Case Objectives Appreciate the prevalence of handoffs and sign out related errors. Understand the key elements of a safe and effective written and verbal sign out. List Kotter’s 8 st…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49648/psn-pdf
    March 01, 2012 - Postdischarge Follow-Up Phone Call March 1, 2012 Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call Case Objectives Understand why preventing readmissions through postdischarge phone calls is important. Describe evidence su…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73200/psn-pdf
    April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions April 28, 2021 Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions The Case  A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and severe e…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49855/psn-pdf
    March 01, 2019 - Which Line: Ordering Provider or Proceduralist? March 1, 2019 Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading to adverse…
  10. psnet.ahrq.gov/Information/Panel
    January 01, 2012 - Browse Author Resources Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33784/psn-pdf
    April 01, 2015 - In Conversation With… David Urbach, MD, MSc April 1, 2015 In Conversation With… David Urbach, MD, MSc. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc Editor's note: Dr. David Urbach is Professor of Surgery and Health Policy, Management, and Evaluation at the University…
  12. psnet.ahrq.gov/primer/simulation-training
    September 15, 2024 - Simulation Training Citation Text: Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
  13. psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
    March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. Citation Text: Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
  14. psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
    June 28, 2023 - SPOTLIGHT CASE Prolonged DKA in Pregnancy: A Case of Communication Breakdown. Citation Text: Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
  15. psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
    January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia Citation Text: Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…
  16. psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
    July 10, 2024 - In Conversation with...Patrick S. Romano, MD, MPH November 1, 2010  Citation Text: In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.In Conversation with...Patrick S. Romano, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
  17. psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
    January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. Citation Text: Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…
  18. psnet.ahrq.gov/issue/implementation-custom-alert-prevent-medication-timing-errors-associated-computerized
    April 25, 2016 - Study Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry. Citation Text: Idemoto LM, Williams BL, Ching JM, et al. Implementation of a custom alert to prevent medication-timing errors associated with computerized presc…
  19. psnet.ahrq.gov/issue/learning-lawsuits-using-malpractice-claims-data-develop-care-transitions-planning-tools
    January 21, 2019 - Study Learning from lawsuits: using malpractice claims data to develop care transitions planning tools. Citation Text: Arbaje AI, Werner NE, Kasda EM, et al. Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools. J Patient Saf. 2020;16(1):52-57.…
  20. psnet.ahrq.gov/issue/patterns-potential-opioid-misuse-and-subsequent-adverse-outcomes-medicare-2008-2012
    June 30, 2021 - Study Patterns of potential opioid misuse and subsequent adverse outcomes in Medicare, 2008 to 2012. Citation Text: Carey CM, Jena AB, Barnett ML. Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes in Medicare, 2008 to 2012. Ann Intern Med. 2018;168(12):837-845. doi:10.7…

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