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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/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.
Citation Text:
Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…
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psnet.ahrq.gov/node/49588/psn-pdf
August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy,
Research, and Patient Care
August 1, 2009
Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
Case…
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psnet.ahrq.gov/node/49540/psn-pdf
August 21, 2007 - Resuscitation Errors: A Shocking Problem
August 21, 2007
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
Case Objectives
Appreciate that delays in defibrillation can have significant negative effects on sur…
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
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psnet.ahrq.gov/node/50929/psn-pdf
February 26, 2020 - Discharged with IV antibiotics: When issues arise, who
manages the complications?
February 26, 2020
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the
complications? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-…
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Danger in Disruption
October 1, 2009
Fontaine DK. Danger in Disruption. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had
metabolic alkalosis (pH = 7.58), and her last peripheral…
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psnet.ahrq.gov/node/38022/psn-pdf
August 27, 2008 - Hospitals try to calm doctors' outbursts: medical road
rage affecting patient safety, group says.
August 27, 2008
Kowalczyk L.
https://psnet.ahrq.gov/issue/hospitals-try-calm-doctors-outbursts-medical-road-rage-affecting-patient-
safety-group-says
This article describes how physician outbursts can affect patient …
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psnet.ahrq.gov/node/845655/psn-pdf
March 08, 2023 - Crisis in the Lakeshore Hospital ER.
March 8, 2023
Derfel A. Montreal Gazette. February 24- March 1, 2023
https://psnet.ahrq.gov/issue/crisis-lakeshore-hospital-er
Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths
associated with emergency care that, w…
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psnet.ahrq.gov/node/60810/psn-pdf
August 12, 2020 - Hospitals Can Take Key Steps to Improve Safe Use of
Digital Systems.
August 12, 2020
Philadelphia, PA: Pew Charitable Trusts; July 21, 2020.
https://psnet.ahrq.gov/issue/hospitals-can-take-key-steps-improve-safe-use-digital-systems
Tracking problems with health information technology (Health IT) is an important st…
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psnet.ahrq.gov/node/41302/psn-pdf
April 18, 2012 - A review of patient safety measures based on routinely
collected hospital data.
April 18, 2012
Tsang C, Palmer WL, Bottle A, et al. A review of patient safety measures based on routinely collected
hospital data. Am J Med Qual. 2012;27(2):154-69. doi:10.1177/1062860611414697.
https://psnet.ahrq.gov/issue/review-pat…
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psnet.ahrq.gov/node/39091/psn-pdf
June 28, 2011 - Integration of prospective and retrospective methods for
risk analysis in hospitals.
June 28, 2011
Kessels-Habraken M, van der Schaaf TW, De Jonge J, et al. Integration of prospective and retrospective
methods for risk analysis in hospitals. Int J Qual Health Care. 2009;21(6):427-32.
doi:10.1093/intqhc/mzp043.
ht…
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psnet.ahrq.gov/node/48054/psn-pdf
June 26, 2019 - Lessons learned from a death outside a hospital's
doorstep.
June 26, 2019
Palmer J. Patient Saf Qual Healthc. May/June 2019.
https://psnet.ahrq.gov/issue/lessons-learned-death-outside-hospitals-doorstep
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be
learned f…
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psnet.ahrq.gov/node/44415/psn-pdf
October 28, 2015 - Medication discrepancies at pediatric hospital discharge.
October 28, 2015
Gattari TB, Krieger LN, Hu HM, et al. Medication Discrepancies at Pediatric Hospital Discharge. Hosp
Pediatr. 2015;5(8):439-45. doi:10.1542/hpeds.2014-0085.
https://psnet.ahrq.gov/issue/medication-discrepancies-pediatric-hospital-discharge
…
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psnet.ahrq.gov/node/40407/psn-pdf
October 04, 2011 - Insights into the climate of safety towards the prevention
of falls among hospital staff.
October 4, 2011
Black AA, Brauer SG, Bell RAR, et al. Insights into the climate of safety towards the prevention of falls
among hospital staff. J Clin Nurs. 2011;20(19-20):2924-30. doi:10.1111/j.1365-2702.2010.03535.x.
https:…
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psnet.ahrq.gov/node/39675/psn-pdf
January 19, 2011 - A 5-year analysis of rapid response system activation at
an in-hospital haemodialysis unit.
January 19, 2011
Galhotra S, Devita MA, Dew MA, et al. A 5-year analysis of rapid response system activation at an in-
hospital haemodialysis unit. Qual Saf Health Care. 2010;19(6):e38. doi:10.1136/qshc.2008.031666.
https:/…
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psnet.ahrq.gov/node/47466/psn-pdf
October 17, 2018 - ASHP guidelines on preventing medication errors in
hospitals.
October 17, 2018
Billstein-Leber M, Carrillo CJD, Cassano AT, et al. ASHP Guidelines on Preventing Medication Errors in
Hospitals. Am J Health-Syst Pharm. 2018;75(19):1493-1517. doi:10.2146/ajhp170811.
https://psnet.ahrq.gov/issue/ashp-guidelines-preven…
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psnet.ahrq.gov/node/72781/psn-pdf
February 24, 2021 - Reducing prescribing errors in hospitalized children on
the ketogenic diet.
February 24, 2021
Siegel BI, Johnson M, Dawson TE, et al. Reducing prescribing errors in hospitalized children on the
ketogenic diet. Pediatr Neurol. 2020;115:42-47. doi:10.1016/j.pediatrneurol.2020.11.009.
https://psnet.ahrq.gov/issue/red…
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psnet.ahrq.gov/node/861776/psn-pdf
January 31, 2024 - The Sunday story: when hospitals don't say sorry.
January 31, 2024
Rascoe A, Gorenstein D. National Public Radio. January 21, 2024.
https://psnet.ahrq.gov/issue/sunday-story-when-hospitals-dont-say-sorry
Openness about making mistakes is a challenge in health care due to fear of litigation and career damage.
This …
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psnet.ahrq.gov/node/60166/psn-pdf
March 25, 2020 - For 4 days, the hospital thought he had just pneumonia. It
was coronavirus.
March 25, 2020
Goldstein J, Salcedo A. For 4 days, the hospital thought he had just pneumonia. It was coronavirus. New
York Times. 2020;March 10.
https://psnet.ahrq.gov/issue/4-days-hospital-thought-he-had-just-pneumonia-it-was-coronavirus…