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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - avoid mix-ups—creative answers can be found nearly
everywhere (eg, even bartender equipment might hold
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - number of unscheduled patients coming to the office on a particular
day, the schedule would have to hold
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psnet.ahrq.gov/node/49794/psn-pdf
May 01, 2017 - with
surgeons' traditional view of their relationship with their patients (3) and their training to "hold
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psnet.ahrq.gov/node/49426/psn-pdf
November 01, 2003 - Per the hospital’s safety protocol, the planned lumbar puncture was put
on hold because of her agitation
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - If
these findings hold true for all Medicare enrollees, then more than 1,900,000 ADEs—more than a quarter
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psnet.ahrq.gov/node/33846/psn-pdf
November 01, 2017 - The Role of Patient-facing Technologies to Empower
Patients and Improve Safety
November 1, 2017
Rozenblum R, Bates DW. The Role of Patient-facing Technologies to Empower Patients and Improve
Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-imp…
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psnet.ahrq.gov/node/49574/psn-pdf
November 01, 2008 - A Mid-Summer Fog
November 1, 2008
Braddock CH. A Mid-Summer Fog. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mid-summer-fog
The Case
A 33-year-old woman with type I diabetes mellitus was admitted for symptoms of left flank pain, dysuria,
and emesis, concerning for pyelonephritis. The patient was taking …
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psnet.ahrq.gov/node/49814/psn-pdf
December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation
Mishap
December 1, 2017
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
The Case
A 63-year-old man with a history of coronary…
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psnet.ahrq.gov/node/33621/psn-pdf
November 01, 2005 - Rapid Response Teams: Lessons from the Early
Experience
November 1, 2005
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
Perspective
Health care organizations throughout the world have ide…
-
psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - "Superficial" Report Leads to "Deep" Problem
December 1, 2009
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
The Case
A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…
-
psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - Wrong-Time Error With High-Alert Medication
September 1, 2016
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
The Case
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
-
psnet.ahrq.gov/node/865418/psn-pdf
March 27, 2024 - Cybersecurity and How to Maintain Patient Safety
March 27, 2024
Pelletreau B, Riggi J, Gale B, et al. Cybersecurity and How to Maintain Patient Safety. PSNet [internet].
2024.
https://psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
Introduction
The integration of information technology (I…
-
psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - Medication Errors and Adverse Drug Events
December 15, 2024
Medication Errors and Adverse Drug Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect cu…
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/issue/international-society-quality-health-care-conference
September 26, 2023 - International Meeting/Conference
International Society for Quality in Health Care Conference.
Citation Text:
International Society for Quality in Health Care, Korean Society for Quality in Health Care, Health Insurance Review and Assessment Service, and the Korea Institute for Healthcare…
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psnet.ahrq.gov/node/33881/psn-pdf
August 01, 2019 - It's not enough to say hold your horses, but we need
to explain to people that it pays to be a little
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psnet.ahrq.gov/node/841566/psn-pdf
December 14, 2022 - These programs hold organizations accountable for quality and safety and make
performance transparent
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psnet.ahrq.gov/web-mm/dropped-no
October 30, 2019 - Several IT innovations under development hold promise to decrease errors: entirely voice activated VRS
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psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
June 07, 2023 - December 6, 2023
WebM&M Cases
Hold That Order
March
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psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - number of unscheduled patients coming to the office on a particular day, the schedule would have to hold