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3981. A Fumbled Handoff to Inpatient Rehab | PSNet
      psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
      December 21, 2018 - A Fumbled Handoff to Inpatient Rehab Citation Text: Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3…

3982. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33597/psn-pdf
      April 10, 2024 - Long-term Care and Patient Safety April 10, 2024 Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/primer/long-term-care-and-patient-safety Background For many years, the patient safety field focused on improving safety in hospital and ambulatory care settings. More re…

3983. Acute Care Admission of the Behavioral Health Patient | PSNet
      psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
      July 19, 2023 - Acute Care Admission of the Behavioral Health Patient Citation Text: Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: …

3984. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49872/psn-pdf
      August 08, 2019 - Spinal Epidural Abscess August 8, 2019 Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess The Case A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a few days of progressive low back pain. She…

3985. An Obstructed View | PSNet
      psnet.ahrq.gov/web-mm/obstructed-view
      August 07, 2019 - An Obstructed View Citation Text: Carter J. An Obstructed View. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

3986. Right Electrocardiogram, Wrong Patient | PSNet
      psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
      April 24, 2024 - Right Electrocardiogram, Wrong Patient Citation Text: Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote…

3987. Primary Workaround, Secondary Complication | PSNet
      psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
      January 24, 2018 - Primary Workaround, Secondary Complication Citation Text: Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar B…

3988. Patient Safety and Adherence to Self-Administered Medications | PSNet
      psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
      September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications Citation Text: Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011…

3989. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49417/psn-pdf
      October 01, 2003 - Lost in the Black Hole October 1, 2003 Wachter R. Lost in the Black Hole. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lost-black-hole The Case A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis. She had a remote history of gonorrhea, no environmental exposu…

3990. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49495/psn-pdf
      December 01, 2005 - Low on the Totem Pole December 1, 2005 Wachter R. Low on the Totem Pole. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/low-totem-pole Case Objectives Understand the concept of authority gradient List steps that can be taken to increase communication across an authority gradient Consider the current cultu…

3991. A Painful Dilemma | PSNet
      psnet.ahrq.gov/web-mm/painful-dilemma
      September 01, 2013 - A Painful Dilemma Citation Text: Davison SN. A Painful Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

3992. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49638/psn-pdf
      January 01, 2012 - Communication Failure—Who's in Charge? October 1, 2011 Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge The Case A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…

3993. New Patient Mistakenly Checked in as Another | PSNet
      psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
      October 01, 2013 - New Patient Mistakenly Checked in as Another Citation Text: Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…

3994. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/861882/psn-pdf
      January 31, 2024 - Patient Safety in Office-Based Care Settings January 31, 2024 Ricciardi R, Lee M, Mossburg S. Patient Safety in Office-Based Care Settings. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings The Institute of Medicine’s 2000 publication To Err Is Human summarized res…

3995. High-Risk Medications, High-Risk Transfers | PSNet
      psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
      December 21, 2017 - High-Risk Medications, High-Risk Transfers Citation Text: Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote …

3996. Is the "Surgical Personality" a Threat to Patient Safety? | PSNet
      psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
      February 24, 2021 - SPOTLIGHT CASE Is the "Surgical Personality" a Threat to Patient Safety? Citation Text: Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citati…

3997. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49640/psn-pdf
      November 01, 2011 - The Case for Patient Flow Management November 1, 2011 Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/case-patient-flow-management The Case A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse wa…

3998. Managing Ascites: Hazards of Fluid Removal | PSNet
      psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
      June 01, 2018 - Managing Ascites: Hazards of Fluid Removal Citation Text: Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

3999. Chest Tube Complications | PSNet
      psnet.ahrq.gov/web-mm/chest-tube-complications
      September 27, 2023 - Chest Tube Complications Citation Text: Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

4000. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/840175/psn-pdf
      November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism. November 16, 2022 Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism The Case A 61-year-old woman presented to …