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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - Mismanagement of Delirium
Citation Text:
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - Project BOOST Increases Patient Understanding of
Treatment and Follow-up Care
May 26, 2021
https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
Summary
The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge
needs,…
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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psnet.ahrq.gov/node/49758/psn-pdf
April 01, 2016 - Dropping to New Lows
April 1, 2016
Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/dropping-new-lows
Case Objectives
State how to manage diabetes medications when patients are admitted to the hospital
Describe a guideline-recommended insulin regimen for a hospitaliz…
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound
and Patient Safety
July 1, 2018
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
Case Objectives
Unders…
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psnet.ahrq.gov/node/49684/psn-pdf
May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical
Error
May 1, 2013
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet].
2013.
https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
Case Objectives
Appreciate that chemotherapy a…
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psnet.ahrq.gov/node/49733/psn-pdf
May 01, 2015 - Transitions in Adolescent Medicine
May 1, 2015
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
The Case
A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the
emer…
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - Annual Perspective
Patient Safety in the Ambulatory Care Setting
August 5, 2022
View more articles from the same authors.
Citation Text:
Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. Rockville (MD): …
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - Nursing and Patient Safety
Citation Text:
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. 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/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.
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - Getting a Good Report Card: Unintended Consequences
of the Public Reporting of Hospital Quality
November 1, 2006
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of
Hospital Quality. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - The Perils of Cross Coverage
May 1, 2012
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/perils-cross-coverage
Case Objectives
Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and
care transitions.
Describe ed…
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psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - Patient Safety in the Ambulatory Care Setting
August 5, 2022
Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
Introduction
There is no way to review the year 2021 in quality and …
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - SPOTLIGHT CASE
A Weighty Mistake
Citation Text:
Bokser SJ. A Weighty Mistake. 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/near-miss-bedside-medications
February 01, 2006 - SPOTLIGHT CASE
Near Miss with Bedside Medications
Citation Text:
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care
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May 26, 2021
Innovation
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psnet.ahrq.gov/issue/near-miss-mixed-methods-analysis-medical-student-assignments-patient-safety
May 25, 2016 - Study
"Near miss": a mixed-methods analysis of medical student assignments in patient safety.
Citation Text:
Plugge T, Breviu A, Lappé K, et al. "Near miss": a mixed-methods analysis of medical student assignments in patient safety. Am J Med Qual. 2024;39(4):168-173. doi:10.1097/jmq.0000…
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psnet.ahrq.gov/issue/quest-eliminate-intrathecal-vincristine-errors-40-year-journey
September 15, 2010 - Commentary
The quest to eliminate intrathecal vincristine errors: a 40-year journey.
Citation Text:
Noble DJ, Donaldson LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf Health Care. 2010;19(4):323-326. doi:10.1136/qshc.2008.030874.
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psnet.ahrq.gov/issue/using-assessment-reasoning-tool-facilitate-feedback-about-diagnostic-reasoning
February 23, 2022 - Study
Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning.
Citation Text:
Cohen AL, Sur M, Falco C, et al. Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. Diagnosis (Berl). 2022;9(4):476-484. doi:10.1515/dx-20…
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psnet.ahrq.gov/issue/effects-learning-climate-and-registered-nurse-staffing-medication-errors
February 15, 2011 - Study
Effects of learning climate and registered nurse staffing on medication errors.
Citation Text:
Chang YK, Mark BA. Effects of Learning Climate and Registered Nurse Staffing on Medication Errors. Nurs Res. 2010;60(1). doi:10.1097/nnr.0b013e3181ff73cc.
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