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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - What Have We Learned About Safe Inpatient Handovers?
March 1, 2011
Kripalani S. What Have We Learned About Safe Inpatient Handovers? PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
Perspective
The care of hospitalized patients is marked by numerous tra…
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psnet.ahrq.gov/node/49775/psn-pdf
November 01, 2016 - Unexpected Drawbacks of Electronic Order Sets
November 1, 2016
McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
The Case
A 70-year-old man with stage 4 prostate cancer presented to the emergency department …
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication
Access Issue
April 1, 2014
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
The Case
A 24-year-old wom…
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psnet.ahrq.gov/node/49613/psn-pdf
November 01, 2010 - Mother's Milk, but Whose Mother?
November 1, 2010
Dougherty D. Mother's Milk, but Whose Mother? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
The Case
A 2-month-old otherwise healthy infant was admitted to the hospital to rule out sepsis. The infant had been
exclusively breastfed…
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psnet.ahrq.gov/node/49398/psn-pdf
May 01, 2003 - Bloody BP Cuff
May 1, 2003
Madan AK. Bloody BP Cuff. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/bloody-bp-cuff
The Case
Patient #1, a 28-year-old male, was a trauma patient following a motor vehicle collision into a cement pillar.
Patient #1 was in the trauma bay with massive injuries and profuse bleed…
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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/49665/psn-pdf
September 01, 2012 - Undetected Foreign Object
September 1, 2012
Cima RR. Undetected Foreign Object. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/undetected-foreign-object
The Case
A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension,
and diabetes was found to have obstruct…
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psnet.ahrq.gov/node/49562/psn-pdf
May 01, 2008 - The Inside of a Time Out
May 1, 2008
Feldman DL. The Inside of a Time Out. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/inside-time-out
The Case
A 65-year-old man was scheduled for an elective endovascular repair of an abdominal aortic aneurysm.
The patient had an allergy to "IV contrast dye" that was no…
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psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital
Citation Text:
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - Glucose Roller Coaster
Citation Text:
Sharpe B. Glucose Roller Coaster. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…
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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - Health Electronic Data Interchange Network (NEHEN) CEO of MA-SHARE (the Regional Health Information Organization
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - This rating system gives each organization (e.g., hospital or nursing home) a star score from 1 to 5
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Some brands use Jackson sizing and others use International Sizing Organization (ISO)
standards.
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - have been multifactorial and have involved many processes, more than one line of responsibility, and organization-wide
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - Brentwood (TN): Organization of Teratology Information Specialists (OTIS); 1994-.
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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - This rating system gives each organization (e.g., hospital or nursing home) a star score from 1 to 5
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psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
March 22, 2009 - billion annually.( 5 )
Despite the high prevalence and ramifications, few health care providers or organizations
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - fraction of that—one fiftieth or one hundredth of that when you look at the budget of AHRQ and other organizations
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psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
June 01, 2010 - Unfortunately, despite growing evidence of the risks of ED boarding, patient safety regulatory organizations
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psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
April 28, 2021 - KH : When you're working with these organizations, what is your role within the in-center program?