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psnet.ahrq.gov/node/49535/psn-pdf
May 01, 2007 - Production Pressures
May 1, 2007
Carayon P. Production Pressures. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/production-pressures
The Case
A 65-year-old man with bipolar disorder was scheduled for maintenance electroconvulsive therapy (ECT), a
procedure he had received dozens of times before. These pro…
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psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
December 18, 2019 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences
Citation Text:
Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…
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psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - Hyperglycemia and Switching to Subcutaneous Insulin
December 1, 2015
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
The Case
A 47-year-old man with type 2 diabetes was admitted to the hospita…
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psnet.ahrq.gov/web-mm/say-it-again
January 31, 2020 - Say It Again
Citation Text:
Henriksen K, Hall KK. Say It Again. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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…
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psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
November 16, 2022 - Are We Pushing Graduate Nurses Too Fast?
Citation Text:
Spector ND. Are We Pushing Graduate Nurses Too Fast? . 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/web-mm/medication-reconciliation-victory-after-avoidable-error
April 01, 2015 - Medication Reconciliation Victory After an Avoidable Error
Citation Text:
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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…
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psnet.ahrq.gov/issue/top-penn-state-health-surgeon-warned-leaders-about-transplant-problems-months-shutdown-then
July 18, 2018 - Newspaper/Magazine Article
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go.
Citation Text:
Top Penn State Health surgeon warned leaders about transplant problems months before shutdown. Then he was let go. Massey W, Keith …
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psnet.ahrq.gov/issue/when-5-rights-go-wrong-medication-errors-nursing-perspective
June 27, 2018 - Study
When the 5 rights go wrong: medication errors from the nursing perspective.
Citation Text:
Jones JH, Treiber LA. When the 5 rights go wrong: medication errors from the nursing perspective. J Nurs Care Qual. 2010;25(3):240-247. doi:10.1097/NCQ.0b013e3181d5b948.
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…
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psnet.ahrq.gov/issue/should-health-care-providers-be-forced-apologise-after-things-go-wrong
March 14, 2016 - Commentary
Should health care providers be forced to apologise after things go wrong?
Citation Text:
McLennan S, Walker S, Rich LE. Should health care providers be forced to apologise after things go wrong? J Bioeth Inq. 2014;11(4):431-5. doi:10.1007/s11673-014-9571-y.
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psnet.ahrq.gov/issue/dont-go-hospital-alone-ensuring-safe-highly-reliable-patient-visitation
May 12, 2021 - Commentary
Don't go to the hospital alone: ensuring safe, highly reliable patient visitation.
Citation Text:
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.
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psnet.ahrq.gov/issue/when-lights-go-down-delivery-room-lessons-ransomware-attack
September 02, 2020 - Commentary
When the lights go down in the delivery room: lessons from a ransomware attack.
Citation Text:
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…
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psnet.ahrq.gov/issue/doing-right-our-patients-when-things-go-wrong-ambulatory-setting
August 14, 2017 - Commentary
Doing right by our patients when things go wrong in the ambulatory setting.
Citation Text:
Schiff G, Griswold P, Ellis BR, et al. Doing right by our patients when things go wrong in the ambulatory setting. Jt Comm J Qual Patient Saf. 2014;40(2):91-96.
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Forma…
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psnet.ahrq.gov/node/49601/psn-pdf
April 01, 2010 - Nosy Business
April 1, 2010
Orlandi RR. Nosy Business. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/nosy-business
The Case
A 59-year-old man with a history of idiopathic thrombocytopenic purpura (ITP) presented to the emergency
department (ED) with epistaxis (a "nose bleed"). He reported no previous h…
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psnet.ahrq.gov/node/49622/psn-pdf
March 01, 2011 - Dropping the Ball Despite an Integrated EMR
March 1, 2011
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
The Case
A patient followed at a community-based clinic that is part of a large health care system with an
in…
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psnet.ahrq.gov/node/49761/psn-pdf
May 01, 2016 - The Fluidity of Diagnostic "Wet Reads"
May 1, 2016
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
The Case
A 64-year-old man with heavy tobacco use presented to the emergency department (ED) with chest pain.
His electroc…
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psnet.ahrq.gov/web-mm/toxic-tachycardia
March 01, 2005 - Toxic Tachycardia
Citation Text:
Wartofsky L. Toxic Tachycardia. 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/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/node/33719/psn-pdf
October 01, 2011 - The Context Is the Intervention
October 1, 2011
Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/context-intervention
Perspective
Introduction
What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this
context.…
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/node/49479/psn-pdf
April 01, 2005 - The Forgotten Med
April 1, 2005
Cucina R. The Forgotten Med. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/forgotten-med
The Case
A 78-year-old woman with a history of chronic obstructive pulmonary disease (COPD) came to the hospital
with increasing shortness of breath and chest pain. Although she had no …