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  1. CVC Placement: Speak Now or Do Not Use the Line | PSNet

    psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
    November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line Citation Text: Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865778/psn-pdf
    May 29, 2024 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement May 29, 2024 Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-complications-unint…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50928/psn-pdf
    February 21, 2020 - Updates in the Role of Health IT in Patient Safety February 21, 2020 Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety Background Health information technology (HIT) has the potential…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846563/psn-pdf
    March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March 2022 conviction of RaDonda Vaught, a former nu…

  6. Complications of Vascular Access Procedures in Patients with Kidney Disease | PSNet

    psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
    November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease Citation Text: Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33736/psn-pdf
    September 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012 In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management at UCLA School of P…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855057/psn-pdf
    October 31, 2023 - Addressing Workplace Violence and Creating a Safer Workplace October 31, 2023 Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace While violence in the w…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853773/psn-pdf
    September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72811/psn-pdf
    September 01, 2022 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Originally published on March 3, 2021 Last updated on March 16, 2021 https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during- initial-treatment Summar…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33885/psn-pdf
    August 01, 2019 - In Conversation With… Susan Smith, MD August 1, 2019 In Conversation With… Susan Smith, MD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-smith-md Editor's note: Dr. Smith, a family medicine physician, is chief faculty practices officer for UCSF Health. Over the past 3–4 years, the …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33668/psn-pdf
    May 01, 2008 - In Conversation with…David W. Bates, MD, MSc May 1, 2008 In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and Quality …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49732/psn-pdf
    May 01, 2015 - Errors in Sepsis Management May 1, 2015 Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/errors-sepsis-management Case Objectives Define sepsis, severe sepsis, and septic shock. Describe the severe sepsis/septic shock resuscitation bundle. Recognize commonly encou…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33822/psn-pdf
    January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA January 1, 2017 In Conversation With… Paul H. O'Neill, MPA. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa Editor's note: Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prio…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33814/psn-pdf
    September 01, 2016 - In Conversation With… Reed V. Tuckson, MD September 1, 2016 In Conversation With… Reed V. Tuckson, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md Editor's note: Dr. Tuckson is Managing Director of Tuckson Health Connections, LLC, and President of the American Telemed…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865376/psn-pdf
    March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures March 27, 2024 Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854848/psn-pdf
    October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures October 31, 2023 Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures The Case A 32-year-old man presented to the hospital with…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49552/psn-pdf
    January 01, 2008 - How Do Providers Recover From Errors? January 1, 2008 West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors Case Objectives Describe the provider-specific prevalence of medical errors. Appreciate the impact of medical errors on care pr…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836841/psn-pdf
    June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission April 7, 2022 https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and- paramedics-provide-home Sum…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49859/psn-pdf
    April 01, 2019 - E-cigarette Explosion in a Patient Room April 1, 2019 Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room The Case A 49-year-old woman was admitted for an exacerbation of chronic obstructive pulmonary disease (COPD) without…
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