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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45266/psn-pdf
    January 01, 2020 - Learning from lawsuits: using malpractice claims data to develop care transitions planning tools. August 31, 2016 Arbaje AI, Werner NE, Kasda EM, et al. Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools. J Patient Saf. 2020;16(1):52-57. doi:10.1097/pts.000000000000023…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867702/psn-pdf
    September 01, 2021 - Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities. September 1, 2021 Agency for Healthcare Research and Quality. Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities. September 2021. https://psnet.ahrq.gov/issue/toolkit-reduce-cauti-and-other-hais-long-term-care-facilities Cathete…
  3. 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…
  4. 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…
  5. 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…
  6. 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-…
  7. 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…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849592/psn-pdf
    May 31, 2023 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans May 31, 2023 https://psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create- customized-prevention Summary Patient falls in hospitals are common and debilitating adverse events that persis…
  9. psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
    January 31, 2020 - Annual Perspective Patient Safety in Medical, Nursing, and Other Clinical Education March 16, 2020  View more articles from the same authors. Citation Text: Howley LD, Hall KK, Fitall E. Patient Safety in Medical, Nursing, and Other Clinical Education . PSNe…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49872/psn-pdf
    August 08, 2019 - Spinal Epidural Abscess August 8, 2019 Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess The Case A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a few days of progressive low back pain. She…
  11. psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
    December 21, 2018 - A Fumbled Handoff to Inpatient Rehab Citation Text: Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  12. 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…
  13. 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…
  14. 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 …
  15. psnet.ahrq.gov/web-mm/hiding-plain-sight
    April 24, 2019 - Hiding in Plain Sight Citation Text: Weinberg JM. Hiding in Plain Sight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
  16. psnet.ahrq.gov/web-mm/forgotten-med
    July 01, 2006 - The Forgotten Med Citation Text: Cucina R. The Forgotten Med. 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 PubMedId RIS …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50389/psn-pdf
    September 25, 2019 - Getting the Diagnosis Both Right and Wrong September 25, 2019 Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong The Case A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33618/psn-pdf
    September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety September 1, 2005 Wachter R. Playing Well with Others: "Translocational Research" in Patient Safety. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety Perspective Translation…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49432/psn-pdf
    February 09, 2004 - Delay in Initiating Antibiotics Results in Fatal Error February 1, 2004 Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error Case Objectives Understand the importance of ongoing patient re-evaluati…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49490/psn-pdf
    September 01, 2005 - The Wrong Channel September 1, 2005 Gosbee JW. The Wrong Channel . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/wrong-channel The Case A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial dosing started at 50 mL/hour using a multi-channel medication pump…

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