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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49787/psn-pdf
    March 01, 2017 - Diagnosing a Missed Diagnosis March 1, 2017 Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis The Case A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and disorientation. She was taking mod…

  2. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
    May 01, 2017 - PowerPoint Presentation Spotlight Diagnostic Delay in the Emergency Department 1 Source and Credits This presentation is based on the May 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…

  3. In Conversation with...Diane Rydrych, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
    February 26, 2025 - In Conversation with...Diane Rydrych, MA June 1, 2007  Citation Text: In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.In Conversation with...Diane Rydrych, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49747/psn-pdf
    December 01, 2015 - Harm From Alarm Fatigue December 1, 2015 Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue Case Objectives Define alarm fatigue and describe potential errors that can occur due to alarm fatigue. Identify federal and national agencies focusing on …

  5. The Wrong Channel | PSNet

    psnet.ahrq.gov/web-mm/wrong-channel
    February 01, 2003 - The Wrong Channel Citation Text: Gosbee JW. The Wrong Channel . 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 RI…

  6. Too Much, Too Fast | PSNet

    psnet.ahrq.gov/web-mm/too-much-too-fast
    June 14, 2019 - Too Much, Too Fast Citation Text: Tuot D. Too Much, Too Fast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  7. Patient Safety Indicators | PSNet

    psnet.ahrq.gov/primer/patient-safety-indicators
    June 15, 2024 - Patient Safety Indicators Citation Text: Tokareva I, Romano P. Patient Safety Indicators.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33596/psn-pdf
    June 01, 2025 - Failure to Rescue January 29, 2025 Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/failure-rescue Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet primers are regularly reviewed and updated to ensure that they reflect cur…

  9. Add-on Case and the Missing Checklist | PSNet

    psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
    September 01, 2012 - Add-on Case and the Missing Checklist Citation Text: Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

  10. In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
    October 06, 2021 - clinical processes and outcomes to ensure that mothers and their babies are receiving evidence-based, recommended

  11. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls | PSNet

    psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
    December 18, 2024 - We have recommended and tested several approaches to improve measurement and communication with staff

  12. The Ongoing Journey to Prevent Patient Falls | PSNet

    psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
    December 18, 2024 - We have recommended and tested several approaches to improve measurement and communication with staff

  13. Health Equity and Maternal Health | PSNet

    psnet.ahrq.gov/perspective/health-equity-and-maternal-health
    October 06, 2021 - clinical processes and outcomes to ensure that mothers and their babies are receiving evidence-based, recommended

  14. In Conversation With... Francoise Marvel, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-francoise-marvel-md
    August 05, 2022 - We can provide patients with recommended apps that help them learn more about their health condition,

  15. Emergence of Application-based Healthcare | PSNet

    psnet.ahrq.gov/perspective/emergence-application-based-healthcare
    August 05, 2022 - We can provide patients with recommended apps that help them learn more about their health condition,

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847934/psn-pdf
    April 26, 2023 - Patient Safety Indicators April 26, 2023 Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/patient-safety-indicators Background Over the past 25 years, policymakers and providers, payers, and purchasers of health care have increasingly focused attention on pati…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850675/psn-pdf
    June 14, 2023 - Patient and Family Roles in Safety June 14, 2023 Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety Moving From Engagement to Partnership Involving patients and families in healthcare decisions about patient c…

  18. Diagnosing a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
    October 26, 2022 - Diagnosing a Missed Diagnosis Citation Text: Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860050/psn-pdf
    January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. January 4, 2024 Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant The Case A 2-month-old full-term male infant was b…

  20. The Hidden Danger of Unseen Intravenous Catheters | PSNet

    psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
    October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters Citation Text: Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google S…
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