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psnet.ahrq.gov/node/49715/psn-pdf
August 21, 2014 - Liver Biopsy: Proceed With Caution
August 21, 2014
Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
The Case
A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast
cancer, presented t…
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psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
September 01, 2005 - Benefits vs. Risks of Intraosseous Vascular Access
Citation Text:
Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
Go…
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psnet.ahrq.gov/node/49674/psn-pdf
December 01, 2012 - Preventing PICC Complications: Whose Line Is It?
December 1, 2012
Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
The Case
A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…
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psnet.ahrq.gov/issue/cultural-transformation-toward-patient-safety-one-conversation-time
November 16, 2022 - Commentary
Cultural transformation toward patient safety: one conversation at a time.
Citation Text:
Moore ML, Putman PA. Cultural transformation toward patient safety: one conversation at a time. Nurs Admin Q. 2008;32(2):102-108. doi:10.1097/01.NAQ.0000314538.36865.09.
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psnet.ahrq.gov/node/836939/psn-pdf
April 27, 2022 - A Virtual Hospitalist Program to Address a Hospital’s
Challenges at the Start of the COVID-19 Pandemic
April 27, 2022
https://psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-
pandemic
Summary
In the early days of the COVID-19 pandemic, New York Presbyterian Weill …
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - one healthcare organization were afraid that if they pushed a weight-
based fluid bolus for morbidly obese
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psnet.ahrq.gov/periodic-issue/periodic-issue-440
May 29, 2024 - May 15, 2024 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, reports, a…
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psnet.ahrq.gov/periodic-issue/periodic-issue-439
May 29, 2024 - May 8, 2024 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, reports, an…
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - January 22, 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, report…
-
psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - January 15, 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, report…
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psnet.ahrq.gov/node/857260/psn-pdf
November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP
(Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
November 30, 2023
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2
Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/when…
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psnet.ahrq.gov/perspective/workplace-safety-health-care
January 01, 2017 - Workplace Safety in Health Care
Ross W. Simon and Elena G. Canacari, RN | January 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Simon RW, Canacari EG. Workplace Safety in Health Care. PSNet [internet]. Rockville (MD):…
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psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA
January 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Paul H. O'Neill, MPA. 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/issue/reflecting-change
December 02, 2009 - Commentary
Reflecting on change.
Citation Text:
Wagstaff R. Reflecting on change. Nurs Manag (Harrow). 2006;13(2):12-7.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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…
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psnet.ahrq.gov/issue/systems-approach-reduce-errors-surgery
August 10, 2016 - Commentary
Systems approach to reduce errors in surgery.
Citation Text:
Dankelman J, Grimbergen CA. Systems approach to reduce errors in surgery. Surg Endosc. 2005;19(8):1017-21.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/node/49662/psn-pdf
August 01, 2012 - Wrong Turn through Colon: Misplaced PEG
August 1, 2012
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
The Case
An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…
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psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - Right? Left? Neither!
May 1, 2006
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-left-neither
Case Objectives
Appreciate the role of Reason's Swiss Cheese Model in medical errors
Understand the process of analyzing a single error
Provide suggestions for …
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psnet.ahrq.gov/issue/long-term-care-healthcare-associated-iinfections-2022-analysis-20216-reports
May 19, 2021 - Study
Long-term care healthcare-associated iInfections in 2022: an analysis of 20,216 reports.
Citation Text:
Kepner S, Bingman C, Jones RM. Long-term care healthcare-associated iInfections in 2022: an analysis of 20,216 reports. Patient Saf. 2023;5(2):20-31. doi:10.33940/001c.74494.
C…
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psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
March 25, 2020 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules
Citation Text:
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/periodic-issue/periodic-issue-418
November 29, 2023 - November 29, 2023 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…