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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…
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psnet.ahrq.gov/node/33731/psn-pdf
June 01, 2012 - An American View of the UK's Patient Safety Enterprise:
Top Down vs. Bottom Up
June 1, 2012
Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
Perspecti…
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psnet.ahrq.gov/perspective/context-intervention
August 05, 2020 - The Context Is the Intervention
Dr. John Øvretveit | October 1, 2011
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Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - New Patient Mistakenly Checked in as Another
Citation Text:
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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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…
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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…
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psnet.ahrq.gov/node/50612/psn-pdf
October 30, 2019 - The Safety Challenges of Supervision and Night Coverage
in Academic Residency
October 30, 2019
Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
The Case…
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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…
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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…
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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…
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psnet.ahrq.gov/node/33670/psn-pdf
July 01, 2008 - In Conversation with...Albert Wu, MD, MPH
July 1, 2008
In Conversation with..Albert Wu, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
Editor's note: Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins
School of Public Health…
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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…
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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…
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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
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July 28, 2021
Innovation
Contact
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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…
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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…
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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…
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psnet.ahrq.gov/node/49662/psn-pdf
August 01, 2012 - Wrong Turn through Colon: Misplaced PEG
August 1, 2012
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
The Case
An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…
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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-…
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psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - Undetected Foreign Object
September 1, 2012
Cima RR. Undetected Foreign Object. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/undetected-foreign-object
The Case
A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension,
and diabetes was found to have obstruct…