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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Measures should be taken to promote the comfort of
those present as well as the equality of all participants
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - Some preemptive measures include thorough preoperative risk assessment and preoperative fasting.
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psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - This focus was provided in large measure by the media.
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - This focus was provided in large measure by the media.
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psnet.ahrq.gov/node/851870/psn-pdf
July 31, 2023 - what happened to bring
attention to this risk through our safety alert program and other marketing measures—all
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - Delay in Appropriate Diagnosis and Treatment Leading to
Death from Pulmonary Embolism
February 10, 2021
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary
Embolism. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leadi…
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psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes
Ross Koppel, PhD | July 1, 2012
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Koppel R. Patient Safety and Health Information Technology: Learning f…
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - SPOTLIGHT CASE
Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism
Citation Text:
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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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
…
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psnet.ahrq.gov/web-mm/missing-suction-tip
January 01, 2006 - SPOTLIGHT CASE
The Missing Suction Tip
Citation Text:
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - Incident Reporting: More Attention to the Safety Action
Feedback Loop, Please
September 1, 2011
Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet
[internet]. 2011.
https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
…
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psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
April 24, 2018 - The Fluidity of Diagnostic "Wet Reads"
Citation Text:
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Medical Devices in the "Wild"
Citation Text:
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
February 26, 2025 - In Conversation With… Erik Hollnagel, PhD
June 1, 2019
Citation Text:
In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Forma…
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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - Haste Makes Care Unsafe
Citation Text:
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
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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…
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Google Scholar BibTeX EndNote X3 XML EndNot…
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psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
October 01, 2011 - SPOTLIGHT CASE
Abdominal Aortic Aneurysm Screening
Citation Text:
Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX E…