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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - Managing Ascites: Hazards of Fluid Removal
Citation Text:
Moore K. Managing Ascites: Hazards of Fluid Removal. 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/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool
Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012
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Citation Text:
Joseph A, Malone EB. The Physical Environment: An Often Unc…
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psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - Critical Order Set Change and Critical Limb Ischemia
Citation Text:
Clay B. Critical Order Set Change and Critical Limb Ischemia. 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/849592/psn-pdf
May 31, 2023 - Preventing Falls Through Patient and Family Engagement
to Create Customized Prevention Plans
May 31, 2023
https://psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-
customized-prevention
Summary
Patient falls in hospitals are common and debilitating adverse events that persis…
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psnet.ahrq.gov/node/850678/psn-pdf
June 14, 2023 - Advance Alert Monitor Program: An Automated Early
Warning System for Adults At Risk for In-Hospital Clinical
Deterioration
June 14, 2023
https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-
risk-hospital
Summary
To address a well-documented hospital adverse outco…
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple
Health System Vulnerabilities
May 26, 2021
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health
System Vulnerabilities. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - Good Catch in the Operating Room
May 1, 2019
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/good-catch-operating-room
The Case
A 46-year-old woman with extensive history of back pain from lumbar stenosis was scheduled for an
elective laminectomy and spinal…
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psnet.ahrq.gov/node/836939/psn-pdf
April 27, 2022 - A Virtual Hospitalist Program to Address a Hospital’s
Challenges at the Start of the COVID-19 Pandemic
April 27, 2022
https://psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-
pandemic
Summary
In the early days of the COVID-19 pandemic, New York Presbyterian Weill …
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psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
September 01, 2015 - Good Night's Sleep Gone Wrong
Citation Text:
Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
August 30, 2023
Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
The COVID-19 pandemic necessitated a shift in operations …
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - Abnormal Volunteer Results
Citation Text:
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Baffled by Botulinum Toxin
Citation Text:
Sivaraman-Nair KP. Baffled by Botulinum Toxin. 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/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
June 28, 2023 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling
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January 31, 2024
Innovation
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psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
January 12, 2011 - Team Training: Classroom Training vs. High-Fidelity Simulation
Stephen D. Pratt, MD and Benjamin P. Sachs, MB | March 1, 2006
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Citation Text:
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulatio…
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psnet.ahrq.gov/perspective/lesson-vas-team-training-program
November 01, 2011 - Lesson from the VA's Team Training Program
Julia Neily, RN, MS, MPH; Peter D. Mills, PhD, MS; Lisa M. Mazzia, MD; and Douglas E. Paull,MD | November 1, 2011
Also Read a Conversation
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Neily J, Mills PD, Pa…
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psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
May 01, 2013 - In Conversation With… Ashish K. Jha, MD, MPH
May 1, 2013
Also Read an Essay
Citation Text:
In Conversation With… Ashish K. Jha, MD, MPH. 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/perspective/conversation-eduardo-salas-phd
November 01, 2011 - In Conversation With… Eduardo Salas, PhD
November 1, 2011
Also Read an Essay
Citation Text:
In Conversation With… Eduardo Salas, PhD . 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/perspective/evolution-root-cause-analysis
February 26, 2025 - – or RCA Squared (RCA 2 ) –an online self-paced course IHI offers, as well as the Patient Safety Executive
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psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
May 14, 2020 - You need to get buy-in from the larger organization, the executive leadership.
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - – or RCA Squared (RCA 2 ) –an online self-paced course IHI offers, as well as the Patient Safety Executive