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psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…
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psnet.ahrq.gov/web-mm/insert-omission
May 09, 2014 - Insert Omission
Citation Text:
Darney P. Insert Omission. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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…
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psnet.ahrq.gov/web-mm/urine-tough-position
January 01, 2009 - Urine a Tough Position
Citation Text:
Gandhi TK. Urine a Tough Position. 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/33638/psn-pdf
August 01, 2006 - Getting Into Patient Safety: A Personal Story
August 1, 2006
Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
Perspective
My journey into patient safety began in 1972. It was born of serendipity enabled by the…
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psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety
Sara J. Singer, MBA, PhD | September 1, 2013
View more articles from the same authors.
Citation Text:
Singer SJ. What We've Learned About Leveraging Leadership a…
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - The Forgotten Drip
Citation Text:
Josephson AS. The Forgotten Drip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - Spotlight Case July 2008
Spotlight Case
All in the History
Source and Credits
This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Christopher Fee, MD, University of California, San Francisco
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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - Dual Therapy Debacle
Citation Text:
Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/misread-label
August 28, 2024 - Misread Label
Citation Text:
Franklin BD. Misread Label. 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/846922/psn-pdf
March 29, 2023 - Enhancing Support for Patients’ Social Needs to Reduce
Hospital Readmissions and Improve Health Outcomes
March 29, 2023
https://psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-
and-improve-health
Summary
With increasing recognition that health is linked to the condit…
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psnet.ahrq.gov/node/49649/psn-pdf
March 01, 2012 - Cultural Dimensions of Depression
March 1, 2012
Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression
The Case
A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability
to breathe and swallow…
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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psnet.ahrq.gov/perspective/safety-dentistry
August 01, 2016 - Safety In Dentistry
Rachel Badovinac Ramoni, DMD, ScD; Muhammad Walji, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD | August 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Ramoni R, Walji MF, Kalenderian E. Safety In De…
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psnet.ahrq.gov/node/867429/psn-pdf
December 18, 2024 - Management of CSF Leaks After Elective Spine Surgery:
Routine Laminectomy Leads to Fatal Discitis and Sepsis
December 18, 2024
Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine
Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. 2024.
https://psnet.ahrq.gov/w…
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psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
March 01, 2008 - Patient safety climate (PSC) perceptions of frontline staff in acute care hospitals: examining
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - For example, systematically examining the process of care from the patient’s entry point into the hospital
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - For example, systematically examining the process of care from the patient’s entry point into the hospital
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psnet.ahrq.gov/node/60790/psn-pdf
February 23, 2022 - Dental care utilization: examining the associations between
health services deficits and not having
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psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - The AGS has done a good job of examining medications that are not good for the elderly.
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psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
February 01, 2014 - Examining a total of 5325 interruptions in a pediatric tertiary care setting, Hall and colleagues found