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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60201/psn-pdf
    April 08, 2020 - Misdiagnosis, mistreatment, and harm - when medical care ignores social forces. April 8, 2020 Holmes SM, Hansen H, Jenks A, et al. Misdiagnosis, mistreatment, and harm - when medical care ignores social forces. N Engl J Med. 2020;382(12). doi:10.1056/nejmp1916269. https://psnet.ahrq.gov/issue/misdiagnosis-mistreat…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846150/psn-pdf
    March 15, 2023 - Patient and health care professional perspectives on stigma in integrated behavioral health: barriers and recommendations. March 15, 2023 Phelan SM, Salinas M, Pankey T, et al. Patient and health care professional perspectives on stigma in integrated behavioral health: barriers and recommendations. Ann Fam Med. 20…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47589/psn-pdf
    January 09, 2019 - Framework for Effective Board Governance of Health System Quality. January 9, 2019 Daley Ullem E, Gandhi TK, Mate K, et al. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018. https://psnet.ahrq.gov/issue/framework-effective-board-governance-health-system-quality The role of hospital boards i…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45963/psn-pdf
    March 22, 2017 - Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response. March 22, 2017 Boston, MA: National Patient Safety Foundation; March 2017. https://psnet.ahrq.gov/issue/call-action-preventable-health-care-harm-public-health-crisis-and-patient-…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34736/psn-pdf
    October 24, 2017 - Medical Problem Solving: An Analysis of Clinical Reasoning. October 24, 2017 Elstein AS, ed. Cambridge, MA: Harvard University Press; 1978. ISBN: 9780674561250. https://psnet.ahrq.gov/issue/medical-problem-solving-analysis-clinical-reasoning Clinical reasoning lies at the heart of formulating diagnoses and selecti…

  6. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units | PSNet

    psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
    April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units Susan McGrath, PhD,George Blike, MD, MHCDS,Bryan M. Gale, MA,Sarah E. Mossburg, RN, PhD | April 26, 2023  Also Read the Conversation View more articles from the same authors. Citation…

  7. Are We Pushing Graduate Nurses Too Fast? | PSNet

    psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
    November 16, 2022 - Are We Pushing Graduate Nurses Too Fast? Citation Text: Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49638/psn-pdf
    January 01, 2012 - Communication Failure—Who's in Charge? October 1, 2011 Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge The Case A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49794/psn-pdf
    May 01, 2017 - Communication Error in a Closed ICU May 1, 2017 Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/communication-error-closed-icu The Case A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney transplant), co…

  10. The Context Is the Intervention | PSNet

    psnet.ahrq.gov/perspective/context-intervention
    August 05, 2020 - The Context Is the Intervention Dr. John Øvretveit | October 1, 2011  View more articles from the same authors. Citation Text: Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49620/psn-pdf
    February 01, 2011 - Silent Pain in the Neck February 1, 2011 Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/silent-pain-neck The Case A 60-year-old man with no significant past medical history underwent an elective anterior cervical discectomy for persistent right arm weakness due to cervi…

  12. One Dose, Fifty Pills | PSNet

    psnet.ahrq.gov/web-mm/one-dose-fifty-pills
    January 13, 2021 - One Dose, Fifty Pills Citation Text: Smith L. One Dose, Fifty Pills . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852699/psn-pdf
    August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety August 30, 2023 Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety The COVID-19 pandemic necessitated a shift in operations …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73229/psn-pdf
    May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities May 26, 2021 Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…

  15. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences | PSNet

    psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
    December 18, 2019 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences Citation Text: Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…

  16. Raise the Bar | PSNet

    psnet.ahrq.gov/web-mm/raise-bar
    May 29, 2024 - Raise the Bar Citation Text: Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  17. Diagnostic Failure: The Growing Deficit | PSNet

    psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
    June 01, 2005 - Diagnostic Failure: The Growing Deficit Citation Text: Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNo…

  18. Can Research Help Us Improve the Medical Liability System? | PSNet

    psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
    March 01, 2012 - Can Research Help Us Improve the Medical Liability System? Allen Kachalia, MD, JD | March 1, 2012  Also Read a Conversation View more articles from the same authors. Citation Text: Kachalia A. Can Research Help Us Improve the Medical Liability System?. PSNet [in…

  19. In Conversation With… Richard C. Boothman, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
    March 01, 2012 - In Conversation With… Richard C. Boothman, JD March 1, 2012  Also Read an Essay Citation Text: In Conversation With… Richard C. Boothman, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866731/psn-pdf
    September 18, 2024 - Root cause analysis of cases involving diagnosis. September 18, 2024 Graber ML, Castro GM, Danforth M, et al. Root cause analysis of cases involving diagnosis. Diagnosis (Berl). 2024;11(4):353-368. doi:10.1515/dx-2024-0102. https://psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis Root cause analy…
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