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psnet.ahrq.gov/node/60039/psn-pdf
March 11, 2020 - A 25-year-old teacher died after waiting hours at the ER.
She's not the only one who saw delays.
March 11, 2020
Linnane R, Diedrich J. Milwaukee Journal Sentinel. February 25, 2020.
https://psnet.ahrq.gov/issue/25-year-old-teacher-died-after-waiting-hours-er-shes-not-only-one-who-saw-
delays
Delays in emergency r…
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psnet.ahrq.gov/issue/systems-approach-analyzing-and-preventing-hospital-adverse-events
March 30, 2022 - Study
Emerging Classic
A systems approach to analyzing and preventing hospital adverse events.
Citation Text:
Leveson N, Samost A, Dekker SWA, et al. A systems approach to analyzing and preventing hospital adverse events. J Patient Saf. 2020;16(2):162-167. doi:1…
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psnet.ahrq.gov/issue/my-patient-ready-safe-transfer-lower-intensity-care-setting-nursing-complexity-independent
April 26, 2023 - Study
Is my patient ready for a safe transfer to a lower-intensity care setting? Nursing complexity as an independent predictor of adverse events risk after ICU discharge.
Citation Text:
Sanson G, Marino C, Valenti A, et al. Is my patient ready for a safe transfer to a lower-intensity ca…
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - SPOTLIGHT CASE
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
Citation Text:
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - Complications of ECMO During Transport
Citation Text:
Broman M. Complications of ECMO During Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Google Scholar BibTeX EndNote X3 XML End…
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psnet.ahrq.gov/node/60721/psn-pdf
July 21, 2020 - to is: If you start doing remote patient monitoring on individuals with chronic conditions, such as
congestive … heart failure and diabetes, how frequently will you need to see them given the remote
monitoring but
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - Perils in Diagnosing a Stroke
Citation Text:
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - SPOTLIGHT CASE
Intraoperative Awareness during Rhinoplasty
Citation Text:
Bohringer C, Toor J. Intraoperative Awareness during Rhinoplasty. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/issue/effect-hospital-wide-measure-readmissions-reduction-program
February 14, 2017 - Study
Effect of a hospital-wide measure on the readmissions reduction program.
Citation Text:
Zuckerman RB, Maddox KEJ, Sheingold SH, et al. Effect of a Hospital-wide Measure on the Readmissions Reduction Program. N Engl J Med. 2017;377(16):1551-1558. doi:10.1056/NEJMsa1701791.
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - fractions in catheterization or ultrasound reports will be more straightforward than assigning class 3 or 4 heart … failure status on the basis of symptoms reported in a history of present illness.
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery
Citation Text:
Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
…
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psnet.ahrq.gov/issue/mortality-due-hospital-acquired-infection-after-cardiac-surgery
February 12, 2020 - Study
Mortality due to hospital-acquired infection after cardiac surgery.
Citation Text:
Massart N, Mansour A, Ross JT, et al. Mortality due to hospital-acquired infection after cardiac surgery. J Thorac Cardiovasc Surg. 2022;163(6):2131-2140.e3. doi:10.1016/j.jtcvs.2020.08.094.
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - SPOTLIGHT CASE
Transfusion Thresholds in Gastrointestinal Bleeding
Citation Text:
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. 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/node/46911/psn-pdf
May 02, 2018 - Errors in electronic health record–based data query of
statin prescriptions in patients with coronary artery
disease in a large, academic, multispecialty clinic
practice.
May 2, 2018
Shin EY, Ochuko P, Bhatt K, et al. Errors in Electronic Health Record-Based Data Query of Statin
Prescriptions in Patients With Cor…
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Errors and Near Misses: What Health Care Could Learn From Aviation
Carl Macrae, PhD | December 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation…
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psnet.ahrq.gov/node/50696/psn-pdf
November 27, 2019 - Patient 2:
A 52-year-old man with a history of ESRD, heart failure, human immunodeficiency virus (HIV
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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - adverse events and hospital performance on 30-day all-cause mortality and readmission for patients with heart … failure.
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psnet.ahrq.gov/node/843150/psn-pdf
December 05, 2022 - In Conversation with... Connor Wesley, RN, BSN on
Patient Safety Concerns and the LGBTQ+ Population
February 1, 2023
In Conversation with.. Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-connor-wesley-rn-bsn-patie…