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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Lost in Transition
February 1, 2006
Beach C. Lost in Transition. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/lost-transition
Case Objectives
Provide an overview of transitions in continuously operating industries
Review cognitive error
Describe the complex dynamics of transitions in emergency care
Pro…
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psnet.ahrq.gov/node/49400/psn-pdf
May 01, 2003 - Central Line Clot
May 1, 2003
Randolph AG. Central Line Clot. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/central-line-clot
Case Objectives
List the complications of central line manipulation
Appreciate the limitations of diagnostic studies for PE in children
Describe modalities for prevention of cathe…
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - Tough Call: Addressing Errors From Previous Providers
March 1, 2014
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
Case Objectives
Define what it means to be a professional.
Identi…
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - SPOTLIGHT CASE
Dangerous Dialysis
Citation Text:
Holley JL. Dangerous Dialysis . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Communication Error in a Closed ICU
Citation Text:
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/techno-trip
May 01, 2005 - Techno Trip
Citation Text:
Cook RI. Techno Trip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downlo…
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Mother's Milk, but Whose Mother?
Citation Text:
Dougherty D. Mother's Milk, but Whose Mother?. 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 EndNote 7 XM…
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance
Measurement Tracking, and Performance Feedback
February 28, 2024
https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-
and-performance
Summary
To improve patient care and outcomes in the intensive care unit (ICU…
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - Failure to Latch
Citation Text:
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
Also Read an Essay
Also Read an Essay
Citation Text:
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.In Conversation with...James P. Bagian, MD. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - Coronavirus Disease 2019 (COVID-19) and Diagnostic
Error
January 11, 2022
Desai AN, Romano PS. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet].
2022.
https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
Originally published July 30, 2020. Updated January …
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psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
November 16, 2022 - A lot of it is probably going to be also diffused through other mechanisms, such as publications, presentations
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psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
October 24, 2021 - KH: Are there formal mechanisms by which pharmacists and clinicians whose patients are coming to them
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - care transitions are an extremely vulnerable time for patients, many clinicians have worked to develop mechanisms
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psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
March 10, 2021 - We need to evolve our PFE mechanisms to better understand how the resources of our hospitals can be mobilized
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psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
January 01, 2015 - Salinas points out that the mechanisms of the various pain medications have been well known for quite
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - How do you take care of your fistula, what are the preparatory mechanisms, what is abnormal, or what
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psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
January 01, 2015 - Salinas points out that the mechanisms of the various pain medications have been well known for quite
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psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
January 01, 2024 - Both mechanisms—CSF extravasation into a pseudomeningocele and inadequate fascial closure— may contribute