-
psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
-
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
…
-
psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…
-
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 …
-
psnet.ahrq.gov/node/49814/psn-pdf
December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation
Mishap
December 1, 2017
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
The Case
A 63-year-old man with a history of coronary…
-
psnet.ahrq.gov/node/33860/psn-pdf
June 01, 2018 - Safety Considerations in Building a Point-of-Care
Ultrasound Program
June 1, 2018
Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
Perspective
At the American Colle…
-
psnet.ahrq.gov/node/49832/psn-pdf
June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error
June 1, 2018
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
The Case
A 33-year-old woman with recently diagnosed acute …
-
psnet.ahrq.gov/node/49487/psn-pdf
August 21, 2005 - Surprise Wire
August 21, 2005
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/surprise-wire
The Case
A 39-year-old man with a history of liver disease presented to the emergency department (ED) with
gastrointestinal bleeding and altered mental status. Due to his clinic…
-
psnet.ahrq.gov/node/49827/psn-pdf
April 01, 2018 - Walking Patient, Missing Drain
April 1, 2018
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain
The Case
A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective
…
-
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…
-
psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
View more articles from the same authors.
Citation Text:
Conway JB, Weingart SN. Organizational Change…
-
psnet.ahrq.gov/node/49742/psn-pdf
September 01, 2015 - A Fumbled Handoff to Inpatient Rehab
September 1, 2015
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
The Case
An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…
-
psnet.ahrq.gov/node/33676/psn-pdf
November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH
November 1, 2008
In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
Editor's note: Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann
Arbor VA …
-
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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote…
-
psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Lethal Cap
Citation Text:
Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Do…
-
psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Strategies to Improve Organizational Health Literacy.
May 31, 2023
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
Background
Health literacy is important at both the personal …
-
psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
January 01, 2015 - So, to many in health care, it is remarkable that the Virginia Mason has integrated innovation and
-
psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
March 27, 2024 - In Conversation With… John Halamka, MD, MS
May 1, 2018
Citation Text:
In Conversation With… John Halamka, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Form…
-
psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety
Ronen Rozenblum, MD, MPH, and David Bates, MD, MS | November 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Rozenblum R, Bates DW. The Role…
-
psnet.ahrq.gov/web-mm/dependence-vs-pain
October 30, 2019 - A trial of integrated buprenorphine/naloxone and HIV clinical care.