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psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - On O.R. Off?
March 1, 2005
Leonard M. On O.R. Off? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/or
The Case
An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography
demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting
…
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psnet.ahrq.gov/node/49551/psn-pdf
December 01, 2007 - Too Hot For Comfort
December 1, 2007
Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/too-hot-comfort
The Case
A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV
antibiotics via a peripheral line in the left antec…
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psnet.ahrq.gov/node/49695/psn-pdf
October 01, 2013 - Finding Fault With the Default Alert
October 1, 2013
Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/finding-fault-default-alert
The Case
A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital
after experiencing …
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psnet.ahrq.gov/node/49406/psn-pdf
June 01, 2003 - The Dangerous Detour
June 1, 2003
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dangerous-detour
The Case
Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service
for observation after being placed on a 72-hour hold by…
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psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - Turn the Other Cheek
March 1, 2012
Starling J. Turn the Other Cheek. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/turn-other-cheek
The Case
A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy
was diagnostic for squamous cell carcinoma (SCC) and docume…
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psnet.ahrq.gov/node/857060/psn-pdf
November 27, 2023 - The Role of Undergraduate Nursing Education in Patient
Safety
November 27, 2023
Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
Introduction
Nurses are a li…
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psnet.ahrq.gov/web-mm/security-lapse
December 18, 2019 - Security Lapse
Citation Text:
Mason D. Security Lapse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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…
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psnet.ahrq.gov/node/33640/psn-pdf
September 01, 2006 - What Can the Rest of the Health Care System Learn from
the VA's Quality and Safety Transformation?
September 1, 2006
Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety
Transformation? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…
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psnet.ahrq.gov/node/49628/psn-pdf
June 01, 2011 - Routine Goes Awry
June 1, 2011
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/routine-goes-awry
The Case
A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and
scheduled for a tonsillectomy and adenoidectomy. She was in ot…
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psnet.ahrq.gov/node/49389/psn-pdf
February 01, 2003 - Procedural Mishap: Learning Curve?
February 1, 2003
Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
The Case
A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had
undesired fert…
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psnet.ahrq.gov/node/49748/psn-pdf
December 01, 2015 - Managing Ascites: Hazards of Fluid Removal
December 1, 2015
Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
The Case
A 50-year-old man with longstanding alcoholic cirrhosis presented to the emergency department (ED) w…
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psnet.ahrq.gov/node/60547/psn-pdf
May 28, 2020 - The Role of the FDA in Ensuring Device Safety
May 28, 2020
Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
Introduction
The Food and Drug Administration (FDA) plays a critical role in ensuring the …
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psnet.ahrq.gov/node/49644/psn-pdf
December 01, 2011 - Missing the Point—Eye Injury
December 1, 2011
Sharma R, Brunette DD. Missing the Point—Eye Injury. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/missing-point-eye-injury
The Case
A 31-year-old woman presented to the emergency department (ED) after suffering multiple lacerations
during an assault. The pati…
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psnet.ahrq.gov/node/72624/psn-pdf
January 05, 2021 - The LifePoint National Quality Program Provides
Structured Framework for Reducing Inpatient Harm
January 5, 2021
https://psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-
reducing-inpatient-harm
Summary
Building on the company’s experience as a Hospital Engagement Network…
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psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety
Sara J. Singer, MBA, PhD | September 1, 2013
View more articles from the same authors.
Citation Text:
Singer SJ. What We've Learned About Leveraging Leadership a…
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psnet.ahrq.gov/node/49507/psn-pdf
April 01, 2006 - Is the "Surgical Personality" a Threat to Patient Safety?
April 1, 2006
Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety? PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
Case Objectives
Describe the myth of the "surgical personality"
Identify featu…
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psnet.ahrq.gov/web-mm/check-bags
January 03, 2017 - Check the Bags
Citation Text:
Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Medication Errors and Adverse Drug Events
Citation Text:
Medication Errors and Adverse Drug Events. 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/citrate-mix
February 01, 2010 - Citrate Mix-Up
Citation Text:
Weber RJ. Citrate Mix-Up. 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/electrocardiogram-results-read-me
May 01, 2019 - Electrocardiogram Results: ***READ ME***
Citation Text:
Alpert JS. Electrocardiogram Results: ***READ ME***. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XM…