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psnet.ahrq.gov/issue/what-every-health-care-organization-should-know-about-sentinel-events
November 27, 2018 - Book/Report
What Every Health Care Organization Should Know about Sentinel Events.
Citation Text:
What Every Health Care Organization Should Know about Sentinel Events. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2005. ISBN 9780866889117.
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psnet.ahrq.gov/issue/diagnosis-interpreting-shadows
June 29, 2016 - Book/Report
Diagnosis: Interpreting the Shadows.
Citation Text:
Diagnosis: Interpreting the Shadows. Croskerry P, Cosby KS, Graber ML, Singh H. Boca Raton, FL: CRC Press; 2017. ISBN: 9781409432333.
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psnet.ahrq.gov/issue/national-medical-error-disclosure-and-compensation-medic-act
December 06, 2011 - Legislation/Case Law
The National Medical Error Disclosure and Compensation (MEDiC) Act.
Citation Text:
The National Medical Error Disclosure and Compensation (MEDiC) Act. Rodham-Clinton H; Obama B. 109th Congress. 1st Session. S. 1784. September 28, 2005.
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psnet.ahrq.gov/issue/ambulatory-safety-and-quality-program-health-it-portfolio-2007-2013
August 01, 2012 - Grant Recipient
Ambulatory Safety and Quality Program: Health IT Portfolio.
Citation Text:
Ambulatory Safety and Quality Program: Health IT Portfolio. Rockville,MD: Agency for Healthcare Research and Quality; July 2010. AHRQ Pub. No. 10-P004.
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psnet.ahrq.gov/issue/foundations-safety-science-century-understanding-accidents-and-disasters
October 05, 2011 - Book/Report
Foundations of Safety Science: a century of understanding accidents and disasters.
Citation Text:
Foundations of Safety Science: a century of understanding accidents and disasters. Dekker S. Taylor & Francis Group, Boca Raton, FL: CRC Press; 2019. ISBN: 978113848178…
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psnet.ahrq.gov/issue/rapid-response-systems-0
April 07, 2010 - Review
Rapid response systems.
Citation Text:
Rapid response systems. Stevens JP. UpToDate. July 18, 2024.
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psnet.ahrq.gov/issue/field-guide-human-error-investigations-third-edition
April 13, 2018 - Book/Report
Classic
The Field Guide to Human Error Investigations, Third Edition.
Citation Text:
The Field Guide to Human Error Investigations, Third Edition. Dekker S. Boca Baton, FL: CRC Press; 2017.
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psnet.ahrq.gov/issue/transforming-health-care-compendium-reports-national-patient-safety-foundations-lucian-leape
November 23, 2016 - Book/Report
Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute.
Citation Text:
Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute. Boston, MA: National …
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psnet.ahrq.gov/issue/mirror-mirror-comparing-health-systems-across-countries
October 07, 2008 - Book/Report
Mirror, Mirror: Comparing Health Systems Across Countries.
Citation Text:
Mirror, Mirror: Comparing Health Systems Across Countries. New York, NY: The Commonwealth Fund; 2004-2024.
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psnet.ahrq.gov/issue/order-chaos-accelerating-care-integration
November 02, 2014 - Book/Report
Order from Chaos: Accelerating Care Integration.
Citation Text:
Order from Chaos: Accelerating Care Integration. Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; October 2012.
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psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
July 01, 2003 - DNR in the OR and Afterwards
Citation Text:
Lo B. DNR in the OR and Afterwards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
January 01, 2015 - PowerPoint Presentation
Spotlight
Monitoring Fetal Health
1
This presentation is based on the January 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Mark W. Scerbo, PhD, Department of Psychology, Old Dominion University, and Alfred Z. Abuham…
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psnet.ahrq.gov/node/49655/psn-pdf
June 01, 2012 - A Painful Dilemma
June 1, 2012
Davison SN. A Painful Dilemma. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/painful-dilemma
The Case
A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with
fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
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psnet.ahrq.gov/node/49601/psn-pdf
April 01, 2010 - Nosy Business
April 1, 2010
Orlandi RR. Nosy Business. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/nosy-business
The Case
A 59-year-old man with a history of idiopathic thrombocytopenic purpura (ITP) presented to the emergency
department (ED) with epistaxis (a "nose bleed"). He reported no previous h…
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in…
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psnet.ahrq.gov/web-mm/patient-mix
December 01, 2007 - Patient Mix-Up
Citation Text:
Shojania KG. Patient Mix-Up. 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/web-mm/weak-response
February 24, 2011 - A "Weak" Response
Citation Text:
Reisman AB. A "Weak" Response. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49416/psn-pdf
September 01, 2003 - Check the Bags
September 1, 2003
Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-bags
The Case
A 50-year-old man with new atrial fibrillation was placed on a diltiazem drip in the emergency department
for rate control. After arriving at the cardiac care unit (CCU…
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psnet.ahrq.gov/node/49500/psn-pdf
January 01, 2006 - Confusion With Acetaminophen
January 1, 2006
Heubi JE. Confusion With Acetaminophen. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/confusion-acetaminophen
The Case
Parents brought their 5-year-old son to the emergency department (ED) with a 24-hour history of fever,
cough, and frontal headache. Physical e…