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psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
March 22, 2009 - For a patient with heart failure, this means making sure I really understand whether this person has
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psnet.ahrq.gov/web-mm/troubling-amine
September 01, 2003 - A Troubling Amine
Citation Text:
Flynn EA. A Troubling Amine. 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/49519/psn-pdf
September 01, 2006 - Triple Handoff
September 1, 2006
Vidyarthi A. Triple Handoff. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/triple-handoff
Case Objectives
Appreciate the prevalence of handoffs and sign out related errors.
Understand the key elements of a safe and effective written and verbal sign out.
List Kotter’s 8 st…
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
June 01, 2017 - The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed?
Vanessa K. Martin, DO, MS; Nasim Mirnateghi, PhD; and Mahdi Khoshchehreh, MD, MS | June 1, 2017
Also Read a Conversation
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Citation Text:
Martin …
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psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
June 01, 2017 - In Conversation With… Paul Aylin, MBChB
June 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Paul Aylin, MBChB. 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/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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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/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/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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…
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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/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/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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…
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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/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
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Citation Text:
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation…
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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/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/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…
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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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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …