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Total Results: 2,840 records

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  1. Two Wrongs Don't Make a Right (Kidney) | PSNet

    psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
    April 01, 2010 - SPOTLIGHT CASE Two Wrongs Don't Make a Right (Kidney) Citation Text: DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Schola…

  2. Is the "Surgical Personality" a Threat to Patient Safety? | PSNet

    psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
    February 24, 2021 - SPOTLIGHT CASE Is the "Surgical Personality" a Threat to Patient Safety? Citation Text: Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citati…

  3. Wandering Off the Floors: Safety and Security Risks of Patient Wandering | PSNet

    psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
    August 21, 2007 - SPOTLIGHT CASE Wandering Off the Floors: Safety and Security Risks of Patient Wandering Citation Text: Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72618/psn-pdf
    December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care December 23, 2020 https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards- medical-decisions Summary Nudges are a change in the way choices ar…

  5. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room | PSNet

    psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
    July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room Citation Text: Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72834/psn-pdf
    March 10, 2021 - Approach to Improving Patient Safety: Communication March 10, 2021 Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication Introduction Each one of the countless necessa…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854848/psn-pdf
    October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures October 31, 2023 Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures The Case A 32-year-old man presented to the hospital with…

  8. Webmm Spotlight Suicide Risk Assessment (pdf file)

    psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
    January 01, 2019 - Spotlight Missed Opportunities for Suicide Risk Assessment Source and Credits • This presentation is based on the November 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Glen Xiong, MD & Debra Kahn, MD ○ Editors in Chief, AHRQ We…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854897/psn-pdf
    October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose October 31, 2023 Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/weight-and-…

  10. Innovations | PSNet

    psnet.ahrq.gov/innovations
    February 26, 2025 - Innovations The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867985/psn-pdf
    January 01, 2025 - Suicide Prevention March 25, 2025 Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024. https://psnet.ahrq.gov/perspective/suicide-prevention Introduction Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in 2022, a 36% rise since 2000…

  12. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation | PSNet

    psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
    November 25, 2020 - Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation Citation Text: Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. …

  13. Personal Health Literacy | PSNet

    psnet.ahrq.gov/primer/personal-health-literacy
    October 31, 2023 - Personal Health Literacy Citation Text: Bakerjian D. Personal Health Literacy. 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 Endnote tagged…

  14. Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care | PSNet

    psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
    July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL December 23, 2020 …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33599/psn-pdf
    August 30, 2023 - Personal Health Literacy August 30, 2023 Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/personal-health-literacy Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…

  16. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose | PSNet

    psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
    March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose Citation Text: Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

  17. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication | PSNet

    psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
    July 02, 2019 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication Citation Text: Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…

  18. Thin Air | PSNet

    psnet.ahrq.gov/web-mm/thin-air
    March 01, 2006 - SPOTLIGHT CASE Thin Air Citation Text: Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  19. Simulation Training | PSNet

    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…

  20. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump | PSNet

    psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
    February 01, 2023 - SPOTLIGHT CASE Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump Citation Text: Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. Rockville (MD): Agency for Heal…
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