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psnet.ahrq.gov/node/866622/psn-pdf
August 28, 2024 - In Conversation with Chalapathy Venkatesan and Kathy
Helak about Application of Safety-II Principles
August 28, 2024
In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-an…
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - But See the Patient First
January 29, 2021
Sinigayan VR. But See the Patient First. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/see-patient-first
The Case
A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief
complaint of fever. Five days previously, he …
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - Palliative Care: Comfort vs. Harm
November 1, 2017
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
Case Objectives
Recognize errors may be difficult to identify in palliative care.
State that medication errors and errors in communica…
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psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - In Conversation With… Richard Kronick, PhD
February 1, 2014
In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since
August 2013 …
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - SPOTLIGHT CASE
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.
Citation Text:
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - SPOTLIGHT CASE
Bad Writing, Wrong Medication
Citation Text:
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - Sudden Collapse During Upper Gastrointestinal
Endoscopy: Expect the Unexpected
August 25, 2021
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-
unexpected
…
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side.
Citation Text:
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
…
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psnet.ahrq.gov/issue/using-machine-learning-improve-patient-safety-home-or-remote-setting-adults
May 25, 2022 - November 3, 2015
Findings and Lessons From the Improving Management of Individuals With
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psnet.ahrq.gov/issue/dana-farber-cancer-institute-principles-fair-and-just-culture
January 11, 2023 - Cohort study of individuals with lung cancer presenting in ambulatory care in the United States.
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - They meet several times to interview individuals who have direct knowledge of the physician's behavior … The fair hearing panel is appointed by the President of the Medical Staff and can only include individuals … Often, individuals feel that their complaints fall into a black hole, are not taken seriously, or will … I appreciate that the leadership of individuals like Dr. … professionals, but the potential impact on patient safety and staff satisfaction caused by problematic individuals
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psnet.ahrq.gov/issue/how-guides-improving-transitions-hospital-reduce-avoidable-rehospitalizations
November 18, 2011 - May 28, 2014
Findings and Lessons From the Improving Management of Individuals With Complex
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - Individuals who work within such a
culture expect professional conduct and feel physically and psychologically … addition, organizations should strive to
build processes for assessing the extent to which systems and/or individuals … risks overlooking important safety threats posed
by underprepared, willfully negligent, or impaired individuals
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psnet.ahrq.gov/web-mm/nosy-business
March 01, 2007 - Most severe nose bleeds of this nature occur in individuals older than 50 years.( 1 ) Anatomy & Epidemiology … Neoplasm is a rare cause but should be considered in individuals with recurring bleeds from the same … Posterior bleeds are more commonly seen in older individuals, and their management is more complex, typically
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psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
March 01, 2004 - Organizations and individuals are increasingly embracing the use of video for learning. … Structured, routine post-action reviews, either by individuals or by teams, are also becoming more prevalent … validated assessment tools ( 3,4 ), clinical protocols, and benchmark performance data become available, individuals
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psnet.ahrq.gov/web-mm/or-peeping
May 01, 2015 - the HIPAA Privacy Rule [45 UFR Prts 160 and 164] covers protected health information (PHI), "about individuals … disclosure of PHI is only likely to be granted if it involves no more than minimal risk to the privacy of individuals … are necessary, we use camera angles and image border controls that allow us to avoid recognition of individuals
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psnet.ahrq.gov/issue/patient-education-materials-assessment-tool-pemat-and-users-guide-instrument-assess
December 24, 2008 - February 4, 2015
Findings and Lessons From the Improving Management of Individuals With
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psnet.ahrq.gov/issue/improving-patient-safety-systems-patients-limited-english-proficiency-guide-hospitals
August 01, 2012 - January 21, 2015
Findings and Lessons From the Improving Management of Individuals With
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psnet.ahrq.gov/issue/peripheral-vision-expertise-real-world-contexts
April 24, 2018 - August 14, 2019
The rise of human factors: optimising performance of individuals and