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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - The Wrong Channel
September 1, 2005
Gosbee JW. The Wrong Channel . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/wrong-channel
The Case
A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial
dosing started at 50 mL/hour using a multi-channel medication pump…
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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…
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psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
November 16, 2022 - Are We Pushing Graduate Nurses Too Fast?
Citation Text:
Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - The Second Victim Phenomenon: A Harsh Reality of
Health Care Professions
May 1, 2011
Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [internet].
2011.
https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
Perspective
The Instit…
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psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - Delay in Initiating Antibiotics Results in Fatal Error
February 1, 2004
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
Case Objectives
Understand the importance of ongoing patient re-evaluati…
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psnet.ahrq.gov/node/33675/psn-pdf
October 01, 2008 - Identifying Adverse Events Not Present on Admission:
Can We Do It?
October 1, 2008
Naessens JM. Identifying Adverse Events Not Present on Admission: Can We Do It? PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
Perspective
Interest is growi…
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - I learned about the development of a measuring tool that, at that point in time, nobody knew anything
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psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
April 01, 2006 - Can you share some of the lessons that you have learned through your work that are relevant to other
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psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
August 31, 2020 - I learned about the development of a measuring tool that, at that point in time, nobody knew anything
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psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
January 01, 2015 - I love reading Don Berwick , Lucian Leape , and others who directly worked with or learned from Dr.
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psnet.ahrq.gov/issue/unprotected-broken-promises-georgias-senior-care-industry
December 04, 2016 - Special or Theme Issue
Unprotected: broken promises in Georgia’s senior care industry.
Citation Text:
Unprotected: broken promises in Georgia’s senior care industry. Schrade B, Teegardin C. Atlanta Journal-Constitution. Sept-October 2019.
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psnet.ahrq.gov/issue/medical-research-and-institutional-review-board-librarians-role-human-subject-testing
June 01, 2022 - Commentary
Medical research and the Institutional Review Board: the librarian's role in human subject testing.
Citation Text:
Medical research and the Institutional Review Board: the librarian's role in human subject testing. Robinson JG; Gehle JL. Reference Services Review. 2005;33(…
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psnet.ahrq.gov/issue/speaking-being-heard-registered-nurses-perceptions-workplace-communication
June 12, 2019 - Study
Speaking up, being heard: registered nurses' perceptions of workplace communication.
Citation Text:
Garon M. Speaking up, being heard: registered nurses' perceptions of workplace communication. J Nurs Manag. 2012;20(3):361-71. doi:10.1111/j.1365-2834.2011.01296.x.
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psnet.ahrq.gov/issue/health-information-technology
August 21, 2016 - Special or Theme Issue
Health Information Technology.
Citation Text:
Health Information Technology. Am J Manag Care. 2014;20(spec 17):492-554,e1-e31.
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psnet.ahrq.gov/issue/when-bone-flap-hits-floor
March 12, 2025 - Study
When the bone flap hits the floor.
Citation Text:
Jankowitz BT, Kondziolka DS. When the bone flap hits the floor. Neurosurgery. 2006;59(3):585-90; discussion 585-90.
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psnet.ahrq.gov/issue/excusable-neglect-malpractice-suits-against-radiologists-proposed-jury-instruction-recognize
April 11, 2011 - Commentary
Excusable neglect in malpractice suits against radiologists: a proposed jury instruction to recognize the human condition.
Citation Text:
Excusable neglect in malpractice suits against radiologists: a proposed jury instruction to recognize the human condition. Caldwell C; …
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psnet.ahrq.gov/issue/point-care-medication-error-prevention-best-practices-action
December 24, 2007 - Newspaper/Magazine Article
Point-of-care medication error prevention: best practices in action.
Citation Text:
Point-of-care medication error prevention: best practices in action. Swenson D. Patient Safety Qual Heathc. May/June 2007.
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psnet.ahrq.gov/issue/beyond-patient-safety-flatland
September 04, 2024 - Commentary
Beyond patient safety Flatland.
Citation Text:
Braithwaite J, Coiera E. Beyond patient safety Flatland. J R Soc Med. 2010;103(6):219-25. doi:10.1258/jrsm.2010.100032.
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psnet.ahrq.gov/issue/importance-simulation-preventing-hand-mistakes
May 20, 2009 - Commentary
The importance of simulation: preventing hand-off mistakes.
Citation Text:
Clancy CM. The importance of simulation: preventing hand-off mistakes. AORN J. 2008;88(4):625-627. doi:10.1016/j.aorn.2008.09.007.
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psnet.ahrq.gov/issue/implementing-patient-safety-alert-system
June 21, 2015 - Study
Implementing a patient safety alert system.
Citation Text:
Furman C. Implementing a patient safety alert system. Nurs Econ. 2005;23(1):42-5.
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Downloa…