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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - Loop Closure
What should health care organizations and facilities do?
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psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
March 07, 2012 - Liver Biopsy: Proceed With Caution
Citation Text:
Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/breakage-picc-line
June 21, 2023 - SPOTLIGHT CASE
Breakage of a PICC Line
Citation Text:
Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
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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.
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Format:
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psnet.ahrq.gov/node/49865/psn-pdf
June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy
June 1, 2019
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
The Case
A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
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psnet.ahrq.gov/node/838855/psn-pdf
October 27, 2022 - False Assumptions Result in a Missed Pneumothorax
after Bronchoscopy with Transbronchial Biopsy.
October 27, 2022
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy
with Transbronchial Biopsy. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
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psnet.ahrq.gov/node/49485/psn-pdf
August 29, 2024 - Blind Spot
June 1, 2005
Lee LA. Blind Spot. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/blind-spot
The Case
A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral
position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - Antibiotics for URI/Sinusitis—A Simple Decision Gone
Bad
April 1, 2008
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
Case Objectives
Understand the indications for antibiotic treatment in …
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psnet.ahrq.gov/node/73899/psn-pdf
September 29, 2021 - Neither report offers specific dosing guidance; both organizations recommend
individualizing therapy … The data in PDMPs are state-specific and various settings/organizations in
addition to hospitals, such
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - Neither report offers specific dosing guidance; both organizations recommend individualizing therapy … The data in PDMPs are state-specific and various settings/organizations in addition to hospitals, such
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - Simultaneously, policymakers and individual EMS organizations are considering the expansion of EMS’ role … Perspective
Patient Safety Events and the Role of Patient Safety Organizations
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psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
August 30, 2023 - We chose to invent our own, but if other organizations are looking for technology, there are many companies … Interview
In Conversation with Timothy Vogus about High Reliability Organization … February 26, 2025
Perspective
High Reliability Organization
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - To Err Is Human observed, external reporting systems can help create an environment that encourages organizations
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - another; Epic, for example, has "Care Everywhere," which allows customers in different health care organizations
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psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
December 07, 2009 - follow-up system.( 3 ) Accordingly, follow-up of outpatient test results has become a major priority for organizations
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psnet.ahrq.gov/node/861881/psn-pdf
January 31, 2024 - I work with professional organizations, with health systems, and with
individuals to develop and operationalize
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - In response to some of the unintended negative consequences of PACS, many organizations have been developing
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - Joint Commission on Accreditation of Healthcare Organizations Web site.
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - Surescripts has built a
network to link prescribers, pharmacy benefit managers, pharmacies, and many other organizations
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psnet.ahrq.gov/node/49486/psn-pdf
August 21, 2005 - Such a vision may be realized in many health care organizations in the next few
years.
Richard H.