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  1. When the Indications for Drug Administration Blur | PSNet

    psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
    May 26, 2021 - Causes of Medication Error and Adverse Outcomes Medication administration is complex and often leads

  2. Root Cause Analysis Gone Wrong | PSNet

    psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - 2022 WebM&M Cases Miscommunication in the OR Leads

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60269/psn-pdf
    April 29, 2020 - This practice generally leads to more efficient consultation from the emergency department and less

  4. Hyperglycemia and Switching to Subcutaneous Insulin | PSNet

    psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
    May 19, 2021 - An electrocardiogram (ECG) was performed and showed T-wave inversions in the lateral leads, prompting

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854897/psn-pdf
    October 31, 2023 - inexperienced https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33723/psn-pdf
    December 01, 2011 - members, and health care staff, and may mark the beginning of a negative cycle where fear of falling leads

  7. Failure to Rescue the Mother | PSNet

    psnet.ahrq.gov/web-mm/failure-rescue-mother
    September 23, 2020 - WebM&M Cases Uterine Artery Injury during Cesarean Delivery Leads

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - or from transfusion-related acute lung injury (TRALI; an immune-related transfusion reaction that leads

  9. In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0 | PSNet

    psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
    February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0 Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD | February 28, 2024  Also Read the Essay Citation Text: In Conversation With..Stephen Hines, PhD an…

  10. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training | PSNet

    psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
    February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD; Zoe Sousane, BS; Sarah Mossburg, RN, PhD | February 28, 2024  Also Read the Conversation View more articles from the same authors. …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851389/psn-pdf
    July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer Summary Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, a…

  12. Robotic Surgery: Risks vs. Rewards | PSNet

    psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
    October 31, 2023 - SPOTLIGHT CASE Robotic Surgery: Risks vs. Rewards Citation Text: Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Googl…

  13. The Deadly Duo | PSNet

    psnet.ahrq.gov/web-mm/deadly-duo
    April 28, 2021 - The Deadly Duo Citation Text: Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33728/psn-pdf
    May 01, 2012 - In Conversation With…David C. Classen, MD, MS May 1, 2012 In Conversation With…David C. Classen, MD, MS. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms Editor's note: David C. Classen, MD, MS, is Chief Medical Information Officer for Pascal Metrics and an Associa…

  15. Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer | PSNet

    psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
    February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 31, 2023 Innovation Contact …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49802/psn-pdf
    August 01, 2017 - Add-on Case and the Missing Checklist August 1, 2017 Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/add-case-and-missing-checklist The Case A 65-year-old woman was admitted for evaluation of abdominal pain and weight loss. Based on diagnostic data and ima…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33658/psn-pdf
    October 01, 2007 - In Conversation with...David Marx, JD October 1, 2007 In Conversation with..David Marx, JD. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd Editor's Note: An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853772/psn-pdf
    September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable September 27, 2023 Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable The Case A fourteen-ye…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33630/psn-pdf
    March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity Simulation March 1, 2006 Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation Point–Counterpoint Editor's Note…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49589/psn-pdf
    August 01, 2009 - Hiding in Plain Sight August 1, 2009 Weinberg JM. Hiding in Plain Sight. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/hiding-plain-sight The Case A 65-year-old woman presented to an emergency department (ED) with 48 hours of nontraumatic left lower back pain and general malaise. She was diagnosed with a …
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