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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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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/node/33752/psn-pdf
August 01, 2013 - In Conversation With… J. Bryan Sexton, PhD, MA
August 1, 2013
In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
Editor's note: J. Bryan Sexton, PhD, is associate professor and director of the Patient Safety Center for
the D…
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - SPOTLIGHT CASE
The Wet Read
Citation Text:
Arenson RL. The Wet Read. 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/33748/psn-pdf
April 01, 2013 - In Conversation With… Christopher P. Landrigan, MD,
MPH
April 1, 2013
In Conversation With… Christopher P. Landrigan, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
Editor's note: Christopher P. Landrigan, MD, is Associate Professor of Medicine and …
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psnet.ahrq.gov/node/865413/psn-pdf
March 27, 2024 - In Conversation with...Barbara Pelletreau and John Riggi
about Cybersecurity
March 27, 2024
Pelletreau B, Riggi J. In Conversation with..Barbara Pelletreau and John Riggi about Cybersecurity. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cyberse…
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - SPOTLIGHT CASE
Delirium or Dementia?
Citation Text:
Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/privacy-or-safety
December 01, 2011 - SPOTLIGHT CASE
Privacy or Safety?
Citation Text:
Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - Unseen Perils of Urinary Catheters
June 1, 2015
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
The Case
A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
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psnet.ahrq.gov/node/838900/psn-pdf
October 27, 2022 - Fecal Contamination of the Peritoneum from
Laparoscopic Trocar Injury: A Routine Operation Goes
Wrong.
October 27, 2022
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine
Operation Goes Wrong. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/fecal-contamination-…
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psnet.ahrq.gov/issue/shift-coupon-innovative-method-monitor-adverse-events
June 25, 2010 - Study
The Shift Coupon: an innovative method to monitor adverse events.
Citation Text:
Kellogg VA, Havens DS. The Shift Coupon: an innovative method to monitor adverse events. J Nurs Care Qual. 2006;21(1):49-55.
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psnet.ahrq.gov/issue/changing-our-culture-adopting-military-aviation-safety-system
November 21, 2021 - Commentary
Changing our culture: adopting the military aviation safety system.
Citation Text:
Kerber CW. Changing our culture: adopting the military aviation safety system. J Neurointerv Surg. 2014;6(5):332-41. doi:10.1136/neurintsurg-2013-011070.
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DOI …
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psnet.ahrq.gov/issue/handbook-human-factors-and-ergonomics-health-care-and-patient-safety-2nd-ed
March 09, 2018 - Book/Report
Classic
Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. 2nd ed.
Citation Text:
Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. 2nd ed. Carayon P, ed. Boca Raton, FL: CRC Press; 2017. ISBN: 97814…
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psnet.ahrq.gov/issue/managing-unexpected-sustained-performance-complex-world-3rd-edition
November 04, 2015 - Book/Report
Classic
Managing the Unexpected: Sustained Performance in a Complex World, Third Edition.
Citation Text:
Managing the Unexpected: Sustained Performance in a Complex World, Third Edition. Weick KE, Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015. I…
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psnet.ahrq.gov/issue/planning-mr-suite-what-can-be-done-enhance-safety
September 12, 2016 - Commentary
Planning an MR suite: what can be done to enhance safety?
Citation Text:
Gilk TB, Kanal E. Planning an MR suite: What can be done to enhance safety? J Magn Reson Imaging. 2015;42(3):566-71. doi:10.1002/jmri.24794.
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psnet.ahrq.gov/issue/perinatal-high-reliability
September 29, 2010 - Review
Perinatal high reliability.
Citation Text:
Knox E, Simpson KR. Perinatal high reliability. Am J Obstet Gynecol. 2011;204(5):373-377. doi:10.1016/j.ajog.2010.10.900.
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psnet.ahrq.gov/issue/ten-years-after-keeping-patients-safe-have-nurses-work-environments-been-transformed
April 04, 2018 - Book/Report
Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed?
Citation Text:
Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed? Princeton, NJ: Robert Wood Johnson Foundation. Washington, DC: George Washington Un…
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psnet.ahrq.gov/issue/algorithmic-bias-playbook
May 13, 2020 - Book/Report
Algorithmic Bias Playbook.
Citation Text:
Algorithmic Bias Playbook. Obermeyer Z, Nissan R, Stern M, et al. Center for Applied Artificial Intelligence, Chicago Booth: June 2021.
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March 01, 2005 - The tendency to take
shortcuts and save time is a very human one, but it also increases the risk of … Lack of predictability greatly
increases the risk of mistakes.