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psnet.ahrq.gov/node/49619/psn-pdf
February 01, 2011 - Paradoxical Pulse
February 1, 2011
Roy CL. Paradoxical Pulse. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/paradoxical-pulse
The Case
An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful
pacemaker placement as an outpatient. The patient was restarted on …
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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - Hold the tPA
April 1, 2005
Fagan SC. Hold the tPA. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hold-tpa
The Case
A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency
department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
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psnet.ahrq.gov/node/33747/psn-pdf
March 01, 2013 - The Literature on Health Care Simulation Education: What
Does It Show?
March 1, 2013
Cook DA. The Literature on Health Care Simulation Education: What Does It Show? PSNet [internet].
2013.
https://psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show
Perspective
The education o…
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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - Chemotherapy Administration Safety Standards
September 1, 2018
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
The Case
A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…
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psnet.ahrq.gov/node/49393/psn-pdf
April 01, 2003 - Which End Is Which?
April 1, 2003
Campbell AR. Which End Is Which? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/which-end-which
The Case
A 39-year-old woman with chronic peri-anal fistulas and infected anal sinuses underwent laparoscopic
diverting colostomy to divert her fecal stream and allow the perine…
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psnet.ahrq.gov/node/33735/psn-pdf
August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and
How to Fix It
August 1, 2012
Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
Perspective
At any point in time, …
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psnet.ahrq.gov/node/36964/psn-pdf
March 24, 2011 - Patients use an internet technology to report when things
go wrong.
March 24, 2011
Wasson JH, MacKenzie TA, Hall M. Patients use an internet technology to report when things go wrong.
Qual Saf Health Care. 2007;16(3):213-5.
https://psnet.ahrq.gov/issue/patients-use-internet-technology-report-when-things-go-wrong
…
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psnet.ahrq.gov/node/853235/psn-pdf
September 06, 2023 - When the lights go down in the delivery room: lessons
from a ransomware attack.
September 6, 2023
Gabbay?Benziv R, Ben?Natan M, Roguin A, et al. When the lights go down in the delivery room: lessons
from a ransomware attack. Int J Gynaecol Obstet. 2023;162(2):562-568. doi:10.1002/ijgo.14687.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/74233/psn-pdf
January 12, 2022 - Don't go to the hospital alone: ensuring safe, highly
reliable patient visitation.
January 12, 2022
Gandhi TK. Don't go to the hospital alone: ensuring safe, highly reliable patient visitation. Jt Comm J Qual
Patient Saf. 2022;48(1):61-64. doi:10.1016/j.jcjq.2021.10.006.
https://psnet.ahrq.gov/issue/dont-go-hospit…
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psnet.ahrq.gov/node/49421/psn-pdf
October 01, 2003 - Urine a Tough Position
October 1, 2003
Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/urine-tough-position
The Case
A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although
she did not want to have a baby at that time, she sta…
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psnet.ahrq.gov/node/33854/psn-pdf
March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety
March 1, 2018
Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
Perspective
Errors in hospitals remain a major cause of death.(1…
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psnet.ahrq.gov/node/49816/psn-pdf
January 01, 2018 - A Painful Medication Reconciliation Mishap
January 1, 2018
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
Case Objectives
Recognize that substance use disorders are common in patients with acute pain.
Understand th…
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psnet.ahrq.gov/node/49705/psn-pdf
January 01, 2020 - A "Reflexive" Diagnosis in Primary Care
April 1, 2014
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
Case Objectives
Appreciate that primary care doctors may be caring for an increasing number of patients wi…
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psnet.ahrq.gov/node/49602/psn-pdf
April 01, 2010 - Anticoagulation: Held Too Long
April 1, 2010
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
The Case
A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was admitted with
abdominal pain. Because of the…
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - Empty Handoff
Citation Text:
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/node/33767/psn-pdf
May 01, 2014 - Innovations in Promoting Hand Hygiene Compliance
May 1, 2014
Marra AR, Edmond MB. Innovations in Promoting Hand Hygiene Compliance. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
Perspective
One hundred sixty-five years after the publication of Ignaz Semmel…
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - SPOTLIGHT CASE
The Other Side
Citation Text:
Vincent CA. The Other Side. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line
Citation Text:
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar …
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psnet.ahrq.gov/node/836836/psn-pdf
March 30, 2022 - Deficiencies after the New Electronic Health Record Go-
Live at the Mann-Grandstaff VA Medical Center in
Spokane, WA.
March 30, 2022
Washington, DC: VA Office of Inspector General; March 17, 2022.
https://psnet.ahrq.gov/issue/deficiencies-after-new-electronic-health-record-go-live-mann-grandstaff-va-
medical-cent…