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4461. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49664/psn-pdf
      January 01, 2013 - Empty Handoff September 1, 2012 Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/empty-handoff The Case A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a leg wound. The patient's medical history included chronic…

4462. No BP During NIBP | PSNet
      psnet.ahrq.gov/web-mm/no-bp-during-nibp
      March 01, 2011 - No BP During NIBP Citation Text: Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

4463. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33645/psn-pdf
      February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? February 1, 2007 Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common Perspectiv…

4464. Reconciling Doses | PSNet
      psnet.ahrq.gov/web-mm/reconciling-doses
      August 14, 2017 - SPOTLIGHT CASE Reconciling Doses Citation Text: Federico F. Reconciling Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

4465. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49869/psn-pdf
      July 02, 2019 - Failure to Rescue the Mother July 2, 2019 Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/failure-rescue-mother The Case A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding. An …

4466. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33730/psn-pdf
      June 01, 2012 - In Conversation With… Charles Vincent, MPhil, PhD June 1, 2012 In Conversation With… Charles Vincent, MPhil, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd Editor's note: Charles Vincent, MPhil, PhD, a psychologist by training, is one of the world's leading p…

4467. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33693/psn-pdf
      February 01, 2010 - The Role of Graduate Medical Education (GME) in Improving Patient Safety February 1, 2010 Baron RB, Vidyarthi A. The Role of Graduate Medical Education (GME) in Improving Patient Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety Perspec…

4468. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49582/psn-pdf
      April 01, 2009 - Breakage of a PICC Line April 1, 2009 Dimov V. Breakage of a PICC Line. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/breakage-picc-line Case Objectives Appreciate the incidence and consequences of PICC line breakage. Understand the risk factors for PICC line breakage. Understand the treatment options in…

4469. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49446/psn-pdf
      August 30, 2021 - Too Tight Control May 1, 2004 Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/too-tight-control Case Objectives Appreciate the advantages and potential complications of intensive insulin therapy in the hospitalized patient List hospital-based safeguards available to…

4470. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865374/psn-pdf
      March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and Challenges March 27, 2024 Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges Introducti…

4471. Defensive Medicine: "Glowing" with Pain | PSNet
      psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
      November 01, 2012 - Defensive Medicine: "Glowing" with Pain Citation Text: Sethi MK. Defensive Medicine: "Glowing" with Pain. 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 E…

4472. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/865864
      January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Diagnostic Error Curated Library Incidence of Diagnostic Errors 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank. Tehrani ASS, Lee HW, Mathews SC, et al. BMJ Qua…

4473. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33596/psn-pdf
      January 29, 2025 - Failure to Rescue January 29, 2025 Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/failure-rescue Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet primers are regularly reviewed and updated to ensure that they reflect cur…

4474. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
      January 01, 2024 - Spotlight Spotlight Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary …

4475. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49687/psn-pdf
      August 21, 2013 - Emergency Error August 21, 2013 Symons NRA. Emergency Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/emergency-error Case Objectives State that emergency surgery is high risk and has high mortality. Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of …

4476. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72618/psn-pdf
      December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care December 23, 2020 https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards- medical-decisions Summary Nudges are a change in the way choices ar…

4477. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49679/psn-pdf
      March 01, 2013 - The Unfamiliar Catheter March 1, 2013 Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/unfamiliar-catheter The Case A 28-year-old woman, 20 months post–bilateral lung transplant, presented to the emergency department with sudden onset of severe shortness of breath…

4478. Two Wrongs Don't Make a Right (Kidney) | PSNet
      psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
      April 01, 2010 - SPOTLIGHT CASE Two Wrongs Don't Make a Right (Kidney) Citation Text: DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Schola…

4479. Home | PSNet
      psnet.ahrq.gov/
      March 14, 2025 - Promoting Patient Safety. Search Apply Advanced Search Search Tips AHRQ’s Patient Safety Network (PSNet) features a collection of the latest news and resources on patient safety, innovations and toolkits , opportunities for CE without a fee and trainings . T…

4480. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33566/psn-pdf
      September 07, 2019 - Teamwork Training September 7, 2019 Teamwork Training. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/teamwork-training PSNet primers are regularly reviewed and updated by the PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Background Providing s…