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psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - Fumbled Handoff
March 1, 2004
Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/fumbled-handoff
The Case
A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and
chronic renal insufficiency was admitted for an elective sigmoid resect…
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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/node/49530/psn-pdf
February 01, 2007 - Rapid Mis-St(r)ep
February 1, 2007
Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/rapid-mis-strep
The Case
A 5-year-old girl was brought to an urgent care center by her father with a 2-day history of fever to 103°F,
sore throat, and diffuse abdominal pain. There was no history…
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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/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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Format:
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psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
August 16, 2023 - Ruptured Heterotopic Pregnancy
Citation Text:
Cedars MI. Ruptured Heterotopic Pregnancy. 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/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
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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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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/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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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - Rescue Improvement Conference Innovation Summary
July 23, 2024
https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
Summary
The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure
to rescue with a particular focus on communication and com…
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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/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/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-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/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-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-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