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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - educational efforts, achieving more timely, reliable diagnoses for rare conditions will likely require innovative
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - though it requires further evaluation in the health care setting, offers some promise.( 25 ) Another innovative
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psnet.ahrq.gov/node/33881/psn-pdf
August 01, 2019 - In Conversation With… Erik Hollnagel, PhD
June 1, 2019
In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden)
as well as Visiting…
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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psnet.ahrq.gov/web-mm/transition-nowhere
March 21, 2009 - Transition to Nowhere
Citation Text:
Farrell TW. Transition to Nowhere. 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/perspective/safety-and-medical-education
December 01, 2013 - Hersh New Investigator Award from AcademyHealth for innovative and high impact research on diagnostic
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - Hersh New Investigator Award from AcademyHealth for innovative and high impact research on diagnostic
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety
December 14, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Dr. Michelle Schreiber on Measuring Patient Safety. PSNet [internet]. 2022.In Conversation With... Dr. Michelle …
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - Measuring Patient Safety
Michelle Schreiber, MD; Cindy Van, MHSA; Sarah E. Mossburg, RN, PhD
| December 14, 2022
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Citation Text:
Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSN…
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psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
October 31, 2023 - In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace
Cheryl B. Jones, PhD, RN, FAAN | October 31, 2023
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Citation Text:
Jones CB. In Conversation with…
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psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
August 01, 2018 - and Microsofts of the world in health care, you wonder whether that will come along with some more innovative
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psnet.ahrq.gov/node/866216/psn-pdf
July 10, 2024 - Health Plan Patient Safety Initiatives
July 10, 2024
Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
When we think of improving patient safety, we often think of strategies that can be implemen…
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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.
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psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications
Citation Text:
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Goo…
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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.
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psnet.ahrq.gov/web-mm/privacy-gone-awry
February 24, 2011 - Privacy Gone Awry
Citation Text:
Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Baffled by Botulinum Toxin
Citation Text:
Sivaraman-Nair KP. Baffled by Botulinum Toxin. 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/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS
David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS | February 1, 2017
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Citation Text:
Baker DP, King HB, Battles J. New Ins…