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psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - Wrong Catheter in the Right Patient
May 27, 2020
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
The Case
A 55-year-old man with history of emphysema was admitted to the hospital for pneumonia. The patient had
two?peripheral…
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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - Getting the Diagnosis Both Right and Wrong
September 25, 2019
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
The Case
A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…
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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/49426/psn-pdf
November 01, 2003 - Don't Push
November 1, 2003
Meltzer HY. Don't Push. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dont-push
The Case
A 37-year-old HIV-positive woman was brought to the emergency room by her family because she had
exhibited altered mentation for 3 days. The patient had been diagnosed with HIV infection 3 …
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psnet.ahrq.gov/web-mm/one-dose-fifty-pills
January 13, 2021 - One Dose, Fifty Pills
Citation Text:
Smith L. One Dose, Fifty Pills
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - ineffective planning and coordination of care at home can thus lead to adverse events and contribute to increased
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psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
May 01, 2008 - successes in changing prescriber behavior have not always been replicated, and users have often reacted to increased
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psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
May 01, 2018 - successes in changing prescriber behavior have not always been replicated, and users have often reacted to increased
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psnet.ahrq.gov/node/33726/psn-pdf
March 01, 2012 - When a surgeon thinks that it's acceptable to do two surgeries at one time (notwithstanding the
increased
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
May 01, 2009 - care system were to do that in, say, Miami, the others would be thrilled because now they would have increased
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - happened and develop solutions in a blame-free environment. 9 One study found that this approach increased
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - happened and develop solutions in a blame-free environment. 9 One study found that this approach increased
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psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
April 24, 2024 - Post-Acute Transitional Services: Safety in Home-Based Care Programs
Citation Text:
McElroy V, Ordona RB, Bakerjian D. Post-Acute Transitional Services: Safety in Home-Based Care Programs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
February 01, 2019 - Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula
Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc | February 1, 2019
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
February 01, 2019 - In Conversation With… Susan E. Skochelak, MD, PhD
February 1, 2019
Also Read an Essay
Citation Text:
In Conversation With… Susan E. Skochelak, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes
Ross Koppel, PhD | July 1, 2012
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Citation Text:
Koppel R. Patient Safety and Health Information Technology: Learning f…
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psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
May 01, 2013 - In Conversation With… Ashish K. Jha, MD, MPH
May 1, 2013
Also Read an Essay
Citation Text:
In Conversation With… Ashish K. Jha, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013…
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psnet.ahrq.gov/web-mm/sick-and-pregnant
August 25, 2021 - Sick and Pregnant
Citation Text:
El-Ibiary S. Sick and Pregnant. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Emerging Safety Issues in Artificial Intelligence
Robert Challen, MA, MBBS | July 1, 2019
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Citation Text:
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare…