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psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - Undetected Foreign Object
September 1, 2012
Cima RR. Undetected Foreign Object. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/undetected-foreign-object
The Case
A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension,
and diabetes was found to have obstruct…
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psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - Wrong Catheter in the Right Patient
May 27, 2020
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
The Case
A 55-year-old man with history of emphysema was admitted to the hospital for pneumonia. The patient had
two?peripheral…
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psnet.ahrq.gov/node/50929/psn-pdf
February 26, 2020 - Discharged with IV antibiotics: When issues arise, who
manages the complications?
February 26, 2020
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the
complications? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-…
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psnet.ahrq.gov/node/33642/psn-pdf
November 01, 2006 - In Conversation With...Donald A. Norman, PhD
November 1, 2006
In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you
become interested…
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psnet.ahrq.gov/node/49433/psn-pdf
June 23, 2021 - Environmental Safety in the OR
February 1, 2004
Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/environmental-safety-or
The Case
The infection control department of a hospital noticed a marked increase in the rates of post-operative
sternal wound inf…
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - Abnormal Volunteer Results
Citation Text:
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/49462/psn-pdf
October 01, 2004 - Thin Air
October 1, 2004
Gaba DM. Thin Air. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/thin-air
Case Objectives
Identify the gas-specific non-interchangeable connectors used for bulk gas supply outlets in
hospitals.
Define forcing function, both in engineered safety devices and in human procedures.
R…
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN
March 1, 2018
In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
Editor's note: Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and
Director of the Ce…
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psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - Right Place, Right Drug, Wrong Strength
Citation Text:
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/privacy-gone-awry
February 24, 2011 - Privacy Gone Awry
Citation Text:
Pauker SG, Pauker SP. Privacy Gone Awry. 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/web-mm/routine-goes-awry
September 23, 2020 - Routine Goes Awry
Citation Text:
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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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.
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psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
January 07, 2015 - Dropping the Ball Despite an Integrated EMR
Citation Text:
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/obstructed-view
August 07, 2019 - An Obstructed View
Citation Text:
Carter J. An Obstructed View. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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…
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psnet.ahrq.gov/node/49417/psn-pdf
October 01, 2003 - Lost in the Black Hole
October 1, 2003
Wachter R. Lost in the Black Hole. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lost-black-hole
The Case
A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis.
She had a remote history of gonorrhea, no environmental exposu…
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psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - How to Identify and Manage Problem Behaviors
December 1, 2009
Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
Perspective
The 1999 Institute of Medicine report highlighted the need for heal…
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - Low on the Totem Pole
December 1, 2005
Wachter R. Low on the Totem Pole. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/low-totem-pole
Case Objectives
Understand the concept of authority gradient
List steps that can be taken to increase communication across an authority gradient
Consider the current cultu…
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psnet.ahrq.gov/web-mm/painful-dilemma
September 01, 2013 - A Painful Dilemma
Citation Text:
Davison SN. A Painful Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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…
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psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
December 21, 2017 - High-Risk Medications, High-Risk Transfers
Citation Text:
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - SPOTLIGHT CASE
Two Wrongs Don't Make a Right (Kidney)
Citation Text:
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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