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psnet.ahrq.gov/node/49719/psn-pdf
September 01, 2014 - No BP During NIBP
September 1, 2014
Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/no-bp-during-nibp
The Case
An otherwise healthy 49-year-old man with atrial fibrillation was scheduled for ablation in the catheterization
laboratory under general endotracheal anes…
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psnet.ahrq.gov/node/837658/psn-pdf
July 08, 2022 - Preventable Transfer to the Hospital
July 8, 2022
Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/preventable-transfer-hospital
The Case
A 78-year-old veteran with dementia-associated aggressive behavior and multiple comorbidities had…
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psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
May 01, 2012 - Situational Awareness and Patient Safety
Citation Text:
Farnan JE. Situational Awareness and Patient Safety. 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/50391/psn-pdf
September 25, 2019 - Think Like a Surgeon
September 25, 2019
Cooper Z. Think Like a Surgeon. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/think-surgeon
The Case
A patient with a history of T6 paraplegia due to a motor vehicle accident was brought to the emergency
department due to delirium. He was found to be hypotensive and…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/node/33881/psn-pdf
August 01, 2019 - In Conversation With… Erik Hollnagel, PhD
June 1, 2019
In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden)
as well as Visiting…
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psnet.ahrq.gov/node/49637/psn-pdf
October 01, 2011 - The Dropped "No"
October 1, 2011
Johnson AJ. The Dropped "No". PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropped-no
The Case
A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in
his legs. Because the leg swelling was somewhat more pronounced in his…
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psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - CVC Removal: A Procedure Like Any Other
June 1, 2014
Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
The Case
A 27-year-old man with a history of Behçet disease and recurrent liver abscesses was admitted to the
hospital for a p…
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psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - To Transfer or Not to Transfer
January 1, 2009
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/transfer-or-not-transfer
Case Objectives
Explore the benefits of the continuity of hospital care.
Understand the rules and regulations behind triage and hospital choice de…
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psnet.ahrq.gov/node/33685/psn-pdf
May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA
May 1, 2009
In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and
Family M…
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces
Hospitalizations Among Nursing Home Residents
July 28, 2021
https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-
home-residents
Summary
The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…
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psnet.ahrq.gov/node/49523/psn-pdf
November 01, 2006 - Urinary Retention Dilemma
November 1, 2006
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma
The Case
Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy
(BPH) and urinary hesitancy returned to th…
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - Inadvertent Castration
Citation Text:
Calland FJ. Inadvertent Castration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/periodic-issue/periodic-issue-472
February 26, 2025 - February 26, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, repor…
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psnet.ahrq.gov/primer/telehealth-and-patient-safety
July 27, 2022 - Telehealth and Patient Safety.
Citation Text:
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
February 01, 2012 - An Untimely End Despite End-of-Life Care Planning
Citation Text:
Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
…
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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - In Conversation with...Geri Amori, PhD
December 1, 2010
Also Read an Essay
Citation Text:
In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010.In Conversation with...Geri Amori, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS | August 28, 2024
Also Read the Essay
View more arti…
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psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
October 30, 2019 - In Conversation With… Neel Shah, MD, MPP
October 30, 2019
Also Read the Essay
Citation Text:
In Conversation With… Neel Shah, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. …
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psnet.ahrq.gov/perspective/application-safety-ii-principles
August 28, 2024 - Application of Safety-II Principles
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS | August 28, 2024
Also Read the Conversation
View more articles from the same authors.
Citation Text:
…