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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Patient Mix-Up
February 1, 2003
Shojania KG. Patient Mix-Up. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/patient-mix
The Case
Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general
medical service at an academic medical center. Overnight, another man wit…
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psnet.ahrq.gov/node/843736/psn-pdf
February 01, 2023 - Saved by ECMO
February 1, 2023
Weiss NA. Saved by ECMO . PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/saved-ecmo
The Case
A 27-year-old pregnant woman was admitted at an estimated gestational age (EGA) of 29 weeks for
increased shortness of breath. She was diagnosed with severe pulmonary arterial hyperte…
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psnet.ahrq.gov/node/33593/psn-pdf
June 15, 2024 - Measurement of Patient Safety
June 15, 2024
Measurement of Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/measurement-patient-safety
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 …
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psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to
Medication Error During Patient Transport
July 31, 2024
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During
Patient Transport. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
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psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
September 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety
Citation Text:
Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - Measurement of Patient Safety
Citation Text:
Measurement of Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/web-mm/outpatient-zebra
January 23, 2020 - An Outpatient 'Zebra'
Citation Text:
Berkowitz L. An Outpatient 'Zebra'. 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 tagged PubMe…
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psnet.ahrq.gov/web-mm/informed-or-misled
April 24, 2018 - Informed or Misled?
Citation Text:
White SM. Informed or Misled?
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - We recognize it’s not the way you spell it, but it is an effective way to remember what our research … Primary care is a team sport, and more and more people recognize and aspire to that.
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psnet.ahrq.gov/web-mm/culture-clash-no-more-integration-and-coordination-disease-treatment-and-palliative-care
December 23, 2020 - to early palliative care referral and intervention Identify reasons patients are lost to follow up Recognize
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psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
September 29, 2021 - indications and contraindications for IO placement
Describe the commonly used sites for IO line insertion
Recognize
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psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
October 31, 2023 - the line between verbal incivility and verbal violence is blurred, making it difficult for staff to recognize … Safety leaders recognize workplace violence as a significant patient safety issue; workforce safety is
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psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
October 31, 2023 - Safety leaders recognize workplace violence as a significant patient safety issue; workforce safety is … the line between verbal incivility and verbal violence is blurred, making it difficult for staff to recognize
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psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
March 01, 2019 - focused on systems thinking, change management, and human factors, is crucial.( 12 ) It is imperative to recognize
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psnet.ahrq.gov/perspective/conversation-withjack-barker-phd
January 01, 2006 - The barriers to effective communication are very important to recognize and then break down.
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psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
March 01, 2013 - to chip away at the evidence base and develop it as far as we can, but at the same time, we have to recognize
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - I recognize that there are currently many barriers and very few resources to assist outpatient providers
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - But it is important to recognize that cultural competence is a separate competence from addressing language
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
January 01, 2004 - synthesis
Verification
Errors in Clinical Decision-Making
Data gathering
Staff not trained to recognize
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psnet.ahrq.gov/webmm/submit-case
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