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psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - Turn the Other Cheek
March 1, 2012
Starling J. Turn the Other Cheek. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/turn-other-cheek
The Case
A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy
was diagnostic for squamous cell carcinoma (SCC) and docume…
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psnet.ahrq.gov/node/60653/psn-pdf
April 25, 2020 - Health Care Delivery and Pharmacists During the COVID-
19 Pandemic
June 29, 2020
Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
Medication…
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psnet.ahrq.gov/node/33797/psn-pdf
January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety
Science, Policy, and Practice
January 1, 2016
Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet
[internet]. 2016.
https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…
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psnet.ahrq.gov/node/836942/psn-pdf
April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake
Patient: Risks of Improper Medication Labeling in an
Operating Room
April 27, 2022
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication
Labeling in an Operating Room. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-m…
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psnet.ahrq.gov/node/49532/psn-pdf
March 15, 2007 - Back to Basics
March 1, 2007
Hellman R. Back to Basics. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/back-basics
The Case
A 48-year-old woman with insulin-dependent diabetes mellitus presents to the emergency department with
right upper quadrant pain, fever, and leukocytosis, prompting admission for pres…
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psnet.ahrq.gov/node/49443/psn-pdf
May 01, 2004 - Privacy Gone Awry
May 1, 2004
Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/privacy-gone-awry
The Case
A 3-year-old child underwent bilateral myringotomies and tube insertion with adenoidectomy.
Preoperatively, she had an upper respiratory infection, but was eating…
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psnet.ahrq.gov/node/33741/psn-pdf
November 01, 2012 - The Evidence-Based Physical Examination as a Patient
Safety Practice
November 1, 2012
McGee S. The Evidence-Based Physical Examination as a Patient Safety Practice. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
Perspective
Near the end of hi…
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psnet.ahrq.gov/node/33876/psn-pdf
August 01, 2018 - Building a Safety Program in a Vast Health Care Network
March 1, 2019
Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
Perspective
Background
As hospital-based health care in the United …
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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
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psnet.ahrq.gov/node/73643/psn-pdf
August 01, 2022 - ECHO-Care Transitions Successfully Reduces Patient
Readmissions from Skilled Nursing Facilities, Reduces
Length of Stay
August 25, 2021
https://psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-
nursing
Summary
ECHO-Care Transitions (ECHO-CT) intends to ensure cont…
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psnet.ahrq.gov/node/72837/psn-pdf
September 01, 2022 - Project Nurture Engages Pregnant People with Substance
Use Disorder, Improves Maternal and Infant Outcomes.
Originally published on March 11, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-
improves-maternal-and
Summary
Project…
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psnet.ahrq.gov/web-mm/hemolysis-holdup
July 03, 2016 - Hemolysis Holdup
Citation Text:
Lehman CM. Hemolysis Holdup. 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/innovation/critical-radiology-alert-process
November 16, 2022 - Critical Radiology Alert Process
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October 30, 2024
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Innovation
Contact
…
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psnet.ahrq.gov/node/72624/psn-pdf
January 05, 2021 - The LifePoint National Quality Program Provides
Structured Framework for Reducing Inpatient Harm
January 5, 2021
https://psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-
reducing-inpatient-harm
Summary
Building on the company’s experience as a Hospital Engagement Network…
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psnet.ahrq.gov/node/33874/psn-pdf
February 01, 2019 - Building Systems Citizenship in Health Professions
Education: The Continued Call for Health Systems
Science Curricula
February 1, 2019
Gonzalo JD, Singh MK. Building Systems Citizenship in Health Professions Education: The Continued Call
for Health Systems Science Curricula. PSNet [internet]. 2019.
https://psnet.…
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psnet.ahrq.gov/node/49755/psn-pdf
February 01, 2016 - Good Night's Sleep Gone Wrong
February 1, 2016
Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
The Case
A 64-year-old woman came to the emergency department complaining of cough and shortness of breath,
along with an…
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psnet.ahrq.gov/node/49515/psn-pdf
July 01, 2006 - Over Not So Easy
July 1, 2006
Cucina R. Over Not So Easy. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/over-not-so-easy
The Case
A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On
admission, she reported allergies to a number of medications as well as a …
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psnet.ahrq.gov/primer/digital-health-literacy
August 30, 2023 - Digital Health Literacy
Citation Text:
Seidel E, Cortes T, Chong C. Digital Health Literacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/little-shuteye
December 22, 2018 - A Little Shuteye
Citation Text:
Farion KJ. A Little Shuteye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix
Leo A. Gordon, MD | September 1, 2007
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Citation Text:
Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The…