-
psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
-
psnet.ahrq.gov/node/43561/psn-pdf
September 24, 2014 - At surgery clinic, rush to save Joan Rivers's life.
September 24, 2014
Hartocollis A, Goodman JD. New York Times. September 9, 2014.
https://psnet.ahrq.gov/issue/surgery-clinic-rush-save-joan-riverss-life
Office-based anesthesia is becoming more common despite concerns regarding its safety. This newspaper
article …
-
psnet.ahrq.gov/issue/deficiencies-community-care-network-credentialing-process-former-va-surgeon-and-veterans
November 29, 2023 - Book/Report
Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures.
Citation Text:
Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administra…
-
psnet.ahrq.gov/issue/inadequate-outpatient-mental-health-triage-and-care-patient-chico-community-based-outpatient
November 29, 2023 - Book/Report
Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.
Citation Text:
Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California. Washing…
-
psnet.ahrq.gov/issue/progress-made-towards-improving-opioid-safety-further-efforts-assess-progress-and-reduce-risk
May 16, 2018 - Book/Report
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.
Citation Text:
Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed. Washington, DC: United States Gov…
-
psnet.ahrq.gov/issue/actions-needed-address-employee-misconduct-process-and-ensure-accountability
July 11, 2018 - Book/Report
Actions Needed to Address Employee Misconduct Process and Ensure Accountability.
Citation Text:
Actions Needed to Address Employee Misconduct Process and Ensure Accountability. Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137. …
-
psnet.ahrq.gov/issue/artificial-intelligence-health-care-benefits-and-challenges-technologies-augment-patient-care
January 08, 2014 - Book/Report
Artificial Intelligence in Health Care: Benefits and Challenges of Technologies to Augment Patient Care.
Citation Text:
Artificial Intelligence in Health Care: Benefits and Challenges of Technologies to Augment Patient Care. Washington DC; United States Government Accountabil…
-
psnet.ahrq.gov/issue/quality-care-concerns-and-facility-response-following-medical-emergency-va-southern-nevada
July 13, 2022 - Book/Report
Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.
Citation Text:
Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care Sy…
-
psnet.ahrq.gov/issue/care-and-oversight-deficiencies-related-multiple-homicides-louis-johnson-va-medical-center
February 10, 2021 - Book/Report
Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.
Citation Text:
Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Vir…
-
psnet.ahrq.gov/issue/infection-control-deficiencies-were-widespread-and-persistent-nursing-homes-prior-covid-19
April 29, 2020 - Book/Report
Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.
Citation Text:
Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic. Washington, DC: United States Government Accoun…
-
psnet.ahrq.gov/issue/deficiencies-care-care-coordination-and-facility-response-patient-who-died-suicide-memphis-va
December 16, 2020 - Book/Report
Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.
Citation Text:
Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center i…
-
psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
-
psnet.ahrq.gov/issue/state-healthcare-2006
April 24, 2013 - Book/Report
State of Healthcare 2008.
Citation Text:
State of Healthcare 2008. The Healthcare Commission. London, UK: The Stationary Office; 2008.
Copy Citation
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
…
-
psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - Death by PCA
Citation Text:
Hicks RW. Death by PCA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
-
psnet.ahrq.gov/issue/deficiencies-emergent-and-outpatient-care-patient-alcohol-use-disorder-richard-l-roudebush-va
July 13, 2022 - Book/Report
Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.
Citation Text:
Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Rou…
-
psnet.ahrq.gov/issue/multiple-failures-test-results-follow-patient-diagnosed-prostate-cancer-hampton-va-medical
July 26, 2023 - Book/Report
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.
Citation Text:
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in V…
-
psnet.ahrq.gov/issue/deficiencies-quality-management-processes-and-delays-communication-test-results-and-follow
March 01, 2023 - Book/Report
Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona.
Citation Text:
Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Fol…
-
psnet.ahrq.gov/node/39872/psn-pdf
February 25, 2013 - The Essential Guide for Patient Safety Officers, Second
Edition.
February 25, 2013
Leonard M, Frankel A, Federico F, et al, eds. Oakbrook Terrace, IL: Joint Commission Resources, Institute
for Healthcare Improvement; 2013. ISBN: 9781599407036.
https://psnet.ahrq.gov/issue/essential-guide-patient-safety-officers-se…
-
psnet.ahrq.gov/issue/report-morecambe-bay-investigation
November 16, 2005 - Book/Report
The Report of the Morecambe Bay Investigation.
Citation Text:
The Report of the Morecambe Bay Investigation. Kirkup B. London, UK: The Stationery Office; 2015. ISBN: 9780108561306.
Copy Citation
Save
Save to your library
Print
Download PDF
…
-
psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Is It Safe to Be Direct?
Citation Text:
Kulkarni NS, Williams M. Is It Safe to Be Direct?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…