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psnet.ahrq.gov/issue/profiles-patient-safety-misplaced-femoral-line-guidewire-and-multiple-failures-detect-foreign
April 03, 2017 - December 21, 2022
Guide to Reducing Unintended Consequences of Electronic Health Records … Cancer
July 31, 2023
Preventing and mitigating radiology system failures: a guide
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psnet.ahrq.gov/issue/hospitalized-patients-understanding-their-plan-care
June 11, 2010 - View More
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psnet.ahrq.gov/issue/high-performance-work-systems-health-care-management-part-1-and-part-2
March 22, 2017 - March 22, 2017
Using Workforce Practices to Drive Quality Improvement: A Guide for Hospitals … June 23, 2010
Guide to Reducing Unintended Consequences of Electronic Health Records.
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psnet.ahrq.gov/issue/opportunities-and-recommendations-state-federal-coordination-improve-health-system
November 29, 2009 - Copy Citation
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2007 Guide to State … November 29, 2009
2014 Guide to State Adverse Event Reporting Systems.
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psnet.ahrq.gov/issue/quality-and-safety-nursing-competency-approach-improving-outcomes-second-edition
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WHO Patient Safety Curriculum Guide: Multi-Professional Edition. … January 29, 2019
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psnet.ahrq.gov/issue/taking-national-action-prevent-and-eliminate-healthcare-associated-infections
May 06, 2015 - October 22, 2013
Guide to Patient and Family Engagement: Environmental Scan Report. … A Pharmacy Health Literacy Assessment Tool User's Guide.
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. 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/865884/psn-pdf
May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening
Complications after Gastric Bypass Surgery.
May 29, 2024
Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…
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psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
December 02, 2020 - Updates in the Management of High-Risk Pulmonary Embolism
Citation Text:
Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Forma…
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
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Inno…
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psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - SPOTLIGHT CASE
CME/MOC
Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.
Citation Text:
Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery.. PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
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August 30, 2023
View more articles from the…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
March 29, 2023 - SPOTLIGHT CASE
CME/MOC
Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation
Citation Text:
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. Roc…
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - SPOTLIGHT CASE
Triple Handoff
Citation Text:
Vidyarthi A. Triple Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/865309/psn-pdf
May 29, 2024 - A Stable Airway? Fatal Airway Occlusion After Inadequate
Post-Tracheostomy Care
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Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-
Tracheostomy Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-i…
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - Syringe Swap During Regional Block: A Case of
Medication Error and Recovery
January 31, 2024
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
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psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - Antiseizure Medication Disorder
May 1, 2007
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
Case Objectives
Appreciate the challenges of safe use of antiepileptic medications.
Identify phenytoin toxicity.
Understand the pharmaco…
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psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
Editor's note: Dr. Edmondson is professor of Leadership and Management at Harvard Business School.
Her la…
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - Seven words that guide every decision made by every leader within Parrish Healthcare from the CEO to