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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49477/psn-pdf
    April 01, 2005 - Hold the tPA April 1, 2005 Fagan SC. Hold the tPA. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hold-tpa The Case A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867980/psn-pdf
    March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls March 25, 2025 Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls. PSNet [internet]. 2025. https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49488/psn-pdf
    August 21, 2005 - PCA Overdose August 21, 2005 Doyle JD. PCA Overdose. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pca-overdose The Case A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo- oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35155/psn-pdf
    April 03, 2008 - Safer Healthcare Now! April 3, 2008 Canadian Patient Safety Institute. https://psnet.ahrq.gov/issue/safer-healthcare-now Originally launched in 2005, this campaign seeks to implement evidence-based strategies to improve patient safety in Canadian hospitals. In April 2008, the initiative added four new intervention…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37660/psn-pdf
    April 02, 2008 - An interdisciplinary approach to safer blood transfusion. April 2, 2008 LaRocco M, Brient K. Patient Saf Qual Healthc. March April 2008. https://psnet.ahrq.gov/issue/interdisciplinary-approach-safer-blood-transfusion This article reports on one hospital's efforts to improve blood transfusion safety by implementing …
  6. psnet.ahrq.gov/perspective/care-transitions
    December 01, 2007 - Care Transitions Sunil Kripalani, MD, MSc | December 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Kripalani S. Care Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depart…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841566/psn-pdf
    December 14, 2022 - In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety December 14, 2022 In Conversation With.. Dr. Michelle Schreiber on Measuring Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety Editor’s Note: Michelle Schr…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36481/psn-pdf
    December 06, 2006 - Introduction to Trigger Tools for Identifying Adverse Events. December 6, 2006 Institute for Healthcare Improvement; IHI https://psnet.ahrq.gov/issue/introduction-trigger-tools-identifying-adverse-events This Web page provides summaries of and links to the various trigger tools available from the Institute for He…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35589/psn-pdf
    June 17, 2010 - Health for life. Keys to safer hospitals. June 17, 2010 Berwick DM. Health for life. 6 keys to safer hospitals. Newsweek. 2005;146(24):76-8. https://psnet.ahrq.gov/issue/health-life-keys-safer-hospitals Institute for Healthcare Improvement President Don Berwick summarizes the six improvement measures of the 100K L…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40864/psn-pdf
    October 19, 2011 - Pressing for better quality across healthcare. October 19, 2011 Levey NN. https://psnet.ahrq.gov/issue/pressing-better-quality-across-healthcare This newspaper article reports on improving US health care and profiles Dr. Donald Berwick, highlighting his commitment and contributions to patient safety and quality wo…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33758/psn-pdf
    December 01, 2013 - In Conversation With… Hardeep Singh, MD, MPH December 1, 2013 In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph Editor's note: Hardeep Singh, MD, MPH, is Chief of the Health Policy, Quality and Informatics Program at the Hous…
  12. psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
    October 30, 2024 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 14, 2023 Innov…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33596/psn-pdf
    June 01, 2025 - Failure to Rescue January 29, 2025 Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/failure-rescue Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet primers are regularly reviewed and updated to ensure that they reflect cur…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49630/psn-pdf
    July 01, 2011 - Watch the Warfarin! July 1, 2011 Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/watch-warfarin Case Objectives Understand best practices for safe discharge of patients on warfarin. Describe recent advances in anticoagulation monitoring for ambulatory patients. Discu…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49687/psn-pdf
    August 21, 2013 - Emergency Error August 21, 2013 Symons NRA. Emergency Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/emergency-error Case Objectives State that emergency surgery is high risk and has high mortality. Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of …
  16. psnet.ahrq.gov/issue/safe-and-appropriate-use-insulin-and-other-antihyperglycemic-agents-hospital
    April 18, 2016 - Review Safe and appropriate use of insulin and other antihyperglycemic agents in hospital. Citation Text: Cornish W. Safe and appropriate use of insulin and other antihyperglycemic agents in hospital. Can J Diabetes. 2014;38(2):94-100. doi:10.1016/j.jcjd.2014.01.002. Copy Citation …
  17. psnet.ahrq.gov/issue/adverse-event-screening-tool-based-routinely-collected-hospital-acquired-diagnoses
    July 23, 2008 - Study An adverse event screening tool based on routinely collected hospital-acquired diagnoses. Citation Text: Brand CA, Tropea J, Gorelik A, et al. An adverse event screening tool based on routinely collected hospital-acquired diagnoses. Int J Qual Health Care. 2012;24(3):266-78. doi:10…
  18. psnet.ahrq.gov/issue/patterns-errors-contributing-trauma-mortality-lessons-learned-2594-deaths
    March 24, 2021 - Study Patterns of errors contributing to trauma mortality: lessons learned from 2,594 deaths. Citation Text: Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of Errors Contributing to Trauma Mortality. Transactions of the .. Meeting of the American Surgical Association. 2006;124. d…
  19. psnet.ahrq.gov/issue/simulation-and-diagnostic-process-pilot-study-trauma-and-rapid-response-teams
    July 16, 2015 - Study Simulation and the diagnostic process: a pilot study of trauma and rapid response teams. Citation Text: Juriga LL, Murray DJ, Boulet JR, et al. Simulation and the diagnostic process: a pilot study of trauma and rapid response teams. Diagnosis (Berl). 2017;4(4):241-249. doi:10.1515/…
  20. psnet.ahrq.gov/issue/supporting-perioperative-safety-during-disaster-through-clinical-crisis-education
    July 05, 2017 - Commentary Supporting perioperative safety during a disaster through clinical crisis education. Citation Text: Kirkman A, Tripp H, Ward L, et al. Supporting perioperative safety during a disaster through clinical crisis education. AORN J. 2024;120(4):226-237. doi:10.1002/aorn.14217. Co…

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