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psnet.ahrq.gov/node/49608/psn-pdf
August 01, 2010 - Emergent Triage Miss
August 1, 2010
Travers D. Emergent Triage Miss. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/emergent-triage-miss
The Case
A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage
nurse. The patient told the triage nurse that she had "3 days o…
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - Tough Call: Addressing Errors From Previous Providers
March 1, 2014
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
Case Objectives
Define what it means to be a professional.
Identi…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - SPOTLIGHT CASE
Right? Left? Neither!
Citation Text:
Chassin MR, Howell EA. Right? Left? Neither!. 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/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - SPOTLIGHT CASE
Engaging Seriously Ill Older Patients in Advance Care Planning
Citation Text:
Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. …
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - Eptifibatide Epilogue
Citation Text:
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - Check the Wristband
Citation Text:
Rosenthal M. Check the Wristband. 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 tagged PubMedId …
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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…
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psnet.ahrq.gov/node/861880/psn-pdf
January 31, 2024 - Patient and Family Centered I-PASS (Family-Centered
Communication Program to Reduce Medical Errors and
Improve Family Experience and Communication
Processes)
January 31, 2024
https://psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-
program-reduce-medical
Summary
Medica…
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. 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/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - SPOTLIGHT CASE
Discharged with IV antibiotics: When issues arise, who manages the complications?
Citation Text:
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure?
October 1, 2008
Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
Case Objectives
Understand the complementary abilities of an electronic health record a…
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psnet.ahrq.gov/web-mm/standard-deviations
January 01, 2006 - SPOTLIGHT CASE
Standard Deviations
Citation Text:
Sabin JE. Standard Deviations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - Delayed Management of Necrotizing Soft Tissue Infection
– Who does the Patient Belong To?
April 29, 2020
Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the
Patient Belong To? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tiss…
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psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
February 26, 2025 - In Conversation With… Ann L. Hendrich, RN, PhD
December 1, 2011
Citation Text:
In Conversation With… Ann L. Hendrich, RN, PhD. 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/node/60721/psn-pdf
July 21, 2020 - Special Edition Perspective: Technology Responses to
COVID-19
July 21, 2020
Marcin JP, Cohen NM, Lowery C, et al. Special Edition Perspective: Technology Responses to COVID-19.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19
Editor’s note: This …
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psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
February 01, 2010 - The Role of Graduate Medical Education (GME) in Improving Patient Safety
Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS | February 1, 2010
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Baron RB, Vidyarthi A. The Role of Gra…
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psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
February 01, 2010 - In Conversation with…Thomas J. Nasca, MD
February 1, 2010
Also Read an Essay
Citation Text:
In Conversation with…Thomas J. Nasca, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
…