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4821. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49417/psn-pdf
      October 01, 2003 - Lost in the Black Hole October 1, 2003 Wachter R. Lost in the Black Hole. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lost-black-hole The Case A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis. She had a remote history of gonorrhea, no environmental exposu…

4822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49495/psn-pdf
      December 01, 2005 - Low on the Totem Pole December 1, 2005 Wachter R. Low on the Totem Pole. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/low-totem-pole Case Objectives Understand the concept of authority gradient List steps that can be taken to increase communication across an authority gradient Consider the current cultu…

4823. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33691/psn-pdf
      December 01, 2009 - How to Identify and Manage Problem Behaviors December 1, 2009 Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors Perspective The 1999 Institute of Medicine report highlighted the need for heal…

4824. The Context Is the Intervention | PSNet
      psnet.ahrq.gov/perspective/context-intervention
      August 05, 2020 - The Context Is the Intervention Dr. John Øvretveit | October 1, 2011  View more articles from the same authors. Citation Text: Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …

4825. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33618/psn-pdf
      September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety September 1, 2005 Wachter R. Playing Well with Others: "Translocational Research" in Patient Safety. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety Perspective Translation…

4826. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33697/psn-pdf
      June 01, 2010 - What Do We Know About Emergency Department Safety? June 1, 2010 Sklar DP, Crandall CS. What Do We Know About Emergency Department Safety? PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety Perspective Emergency medicine has evolved from a location, with var…

4827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49554/psn-pdf
      January 01, 2008 - Chemotherapy Extravasation January 1, 2008 Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation The Case A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and her oncologist decided to begin sys…

4828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49706/psn-pdf
      January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue April 1, 2014 Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue The Case A 24-year-old wom…

4829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33722/psn-pdf
      December 01, 2011 - In Conversation With… Ann L. Hendrich, RN, PhD December 1, 2011 In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd Editor's note: Ann L. Hendrich, RN, PhD, is Vice President of Clinical Excellence Operations and Executive Di…

4830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50696/psn-pdf
      November 27, 2019 - Complications of Vascular Access Procedures in Patients with Kidney Disease November 27, 2019 Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease The Ca…

4831. Abnormal Volunteer Results | PSNet
      psnet.ahrq.gov/web-mm/abnormal-volunteer-results
      July 18, 2016 - Abnormal Volunteer Results Citation Text: Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

4832. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33820/psn-pdf
      December 01, 2016 - In Conversation With... James P. Bagian, MD, PE December 1, 2016 In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe Editor's note: Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the Uni…

4833. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49398/psn-pdf
      May 01, 2003 - Bloody BP Cuff May 1, 2003 Madan AK. Bloody BP Cuff. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/bloody-bp-cuff The Case Patient #1, a 28-year-old male, was a trauma patient following a motor vehicle collision into a cement pillar. Patient #1 was in the trauma bay with massive injuries and profuse bleed…

4834. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60652/psn-pdf
      June 29, 2020 - In Conversation With... Anna Legreid Dopp, Pharm. D June 29, 2020 In Conversation With.. Anna Legreid Dopp, Pharm. D. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d Editor’s note: Anna Legreid Dopp, Pharm. D is the Senior Director of Clinical Guidelines and Quality…

4835. Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents | PSNet
      psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-home-residents
      July 23, 2024 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 28, 2021 Innovation Contact …

4836. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49433/psn-pdf
      June 23, 2021 - Environmental Safety in the OR February 1, 2004 Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/environmental-safety-or The Case The infection control department of a hospital noticed a marked increase in the rates of post-operative sternal wound inf…

4837. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49863/psn-pdf
      May 01, 2019 - Good Catch in the Operating Room May 1, 2019 Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/good-catch-operating-room The Case A 46-year-old woman with extensive history of back pain from lumbar stenosis was scheduled for an elective laminectomy and spinal…

4838. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73998/psn-pdf
      October 27, 2021 - The Hidden Danger of Unseen Intravenous Catheters October 27, 2021 Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters The Case A 6-week-old infant underwent a craniotomy and excision of abnormal bra…

4839. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49593/psn-pdf
      October 01, 2009 - Who Nose Where the Airway Is? October 1, 2009 Lee CR. Who Nose Where the Airway Is? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/who-nose-where-airway The Case A 70-year-old man with peripheral vascular disease was brought to the operating room to undergo vascular bypass surgery on his right upper extrem…

4840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50929/psn-pdf
      February 26, 2020 - Discharged with IV antibiotics: When issues arise, who manages the complications? February 26, 2020 Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-…