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psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
April 24, 2018 - The Fluidity of Diagnostic "Wet Reads"
Citation Text:
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/49545/psn-pdf
September 01, 2007 - Coming Undone: Failure of Closure Device
September 1, 2007
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
The Case
A 65-year-old man underwent coronary angiography because of atypical exertional chest…
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/node/49677/psn-pdf
February 01, 2013 - CVC Placement: Speak Now or Do Not Use the Line
February 1, 2013
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
The Case
A 48-year-old woman with a history of hypertension, psychiatric illness, and a…
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psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - Diagnosing a Missed Diagnosis
March 1, 2017
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
The Case
A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and
disorientation. She was taking mod…
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psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - Breakage of a PICC Line
April 1, 2009
Dimov V. Breakage of a PICC Line. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/breakage-picc-line
Case Objectives
Appreciate the incidence and consequences of PICC line breakage.
Understand the risk factors for PICC line breakage.
Understand the treatment options in…
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psnet.ahrq.gov/node/33672/psn-pdf
September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH
September 1, 2008
In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
Editor's note: Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women's
Hospital and Assi…
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psnet.ahrq.gov/node/49693/psn-pdf
October 01, 2013 - It's Sarah, Not Stephen!
October 1, 2013
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/its-sarah-not-stephen
Case Objectives
Define and distinguish the terms gender identity, gender expression, and gender variance.
Delineate patient safety issues associated with transge…
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psnet.ahrq.gov/node/42531/psn-pdf
December 06, 2013 - Is evidence guiding practice? Reported versus observed
adherence to contact precautions: a pilot study.
December 6, 2013
Jessee MA, Mion LC. Is evidence guiding practice? Reported versus observed adherence to contact
precautions: a pilot study. Am J Infect Control. 2013;41(11):965-70. doi:10.1016/j.ajic.2013.05.005…
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psnet.ahrq.gov/issue/root-cause-analysis-and-actions-prevention-medical-errors-quality-improvement-and-resident
October 19, 2016 - Guide to curricular development and evaluation of longer-term resident perceptions. … October 16, 2019
I-PASS Mentored Implementation Handoff Curriculum: implementation guide
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psnet.ahrq.gov/issue/patient-safety-ambulatory-settings
June 08, 2011 - October 26, 2016
Designing and Delivering Whole-Person Transitional Care: Hospital Guide … December 7, 2018
Guide to Improving Patient Safety in Primary Care Settings by Engaging
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psnet.ahrq.gov/node/44723/psn-pdf
December 16, 2015 - Situation, background, assessment, and
recommendation–guided huddles improve
communication and teamwork in the emergency
department.
December 16, 2015
Martin HA, Ciurzynski SM. Situation, Background, Assessment, and Recommendation-Guided Huddles
Improve Communication and Teamwork in the Emergency Department. Jour…
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psnet.ahrq.gov/node/38330/psn-pdf
September 24, 2010 - Medication safety teams' guided implementation of
electronic medication administration records in five
nursing homes.
September 24, 2010
Scott-Cawiezell J, Madsen RW, Pepper GA, et al. Medication safety teams' guided implementation of
electronic medication administration records in five nursing homes. Jt Comm J Qu…
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psnet.ahrq.gov/node/847730/psn-pdf
February 26, 2018 - “Brave men” and “emotional women”: a theory-guided
literature review on gender bias in health care and
gendered norms towards patients with chronic pain.
February 26, 2018
Samulowitz A, Gremyr I, Eriksson E, et al. “Brave men” and “emotional women”: a theory-guided literature
review on gender bias in health care a…
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psnet.ahrq.gov/node/37560/psn-pdf
March 28, 2018 - the United Kingdom, this report identifies common themes
and addresses how such investigations can guide
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psnet.ahrq.gov/node/39509/psn-pdf
August 08, 2010 - Bad stars or guiding lights? Learning from disasters to
improve patient safety.
August 8, 2010
Hughes C, Travaglia JF, Braithwaite J. Bad stars or guiding lights? Learning from disasters to improve
patient safety. Qual Saf Health Care. 2010;19(4):332-6. doi:10.1136/qshc.2008.030148.
https://psnet.ahrq.gov/issue/ba…
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psnet.ahrq.gov/node/36708/psn-pdf
April 21, 2011 - Missed breast cancers at US-guided core needle biopsy:
how to reduce them.
April 21, 2011
Youk JH, Kim E-K, Kim MJ, et al. Missed breast cancers at US-guided core needle biopsy: how to reduce
them. Radiographics. 2007;27(1):79-94.
https://psnet.ahrq.gov/issue/missed-breast-cancers-us-guided-core-needle-biopsy-how-…
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psnet.ahrq.gov/node/35009/psn-pdf
May 27, 2011 - Guided prescription of psychotropic medications for
geriatric inpatients.
May 27, 2011
Peterson JF, Kuperman GJ, Shek C, et al. Guided prescription of psychotropic medications for geriatric
inpatients. Arch Intern Med. 2005;165(7):802-7.
https://psnet.ahrq.gov/issue/guided-prescription-psychotropic-medications-ger…
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psnet.ahrq.gov/node/40764/psn-pdf
December 29, 2014 - Wristbands as aids to reduce misidentification: an
ethnographically guided task analysis.
December 29, 2014
Smith A, Casey K, Wilson J, et al. Wristbands as aids to reduce misidentification: an ethnographically
guided task analysis. Int J Qual Health Care. 2011;23(5):590-9. doi:10.1093/intqhc/mzr045.
https://psnet…
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - March 20, 2019
Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era