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psnet.ahrq.gov/issue/how-could-happen
September 19, 2007 - Newspaper/Magazine Article
How could this happen?
Citation Text:
How could this happen? Westfall SS; Mascia K. People. October 5, 2009.
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psnet.ahrq.gov/issue/my-human-doctor
November 18, 2020 - Newspaper/Magazine Article
My human doctor.
Citation Text:
My human doctor. Peskin SM. New York Times. October 4, 2018.
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psnet.ahrq.gov/issue/partnering-patients-and-families-enhance-safety-and-quality-mini-toolkit
September 12, 2018 - Toolkit
Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit.
Citation Text:
Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit. Bethesda, MD: Institute for Patient- and Family-Centered Care; 2011.
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psnet.ahrq.gov/issue/2008-recommendations-pre-anesthesia-checkout-procedures
April 22, 2020 - Organizational Policy/Guidelines
2008 Recommendations for Pre-Anesthesia Checkout Procedures.
Citation Text:
2008 Recommendations for Pre-Anesthesia Checkout Procedures. ASA Committee on Equipment and Facilities. Park Ridge, IL: American Society of Anesthesiologists; 2008.
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psnet.ahrq.gov/issue/ismp-medication-safety-self-assessmentr-perioperative-settings
January 26, 2023 - Measurement Tool/Indicator
ISMP Medication Safety Self Assessment® for Perioperative Settings.
Citation Text:
ISMP Medication Safety Self Assessment® for Perioperative Settings. Institute for Safe Medication Practices
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psnet.ahrq.gov/issue/medical-residents-angered-extended-work-hours
April 27, 2016 - Newspaper/Magazine Article
Medical residents angered at extended work hours.
Citation Text:
Medical residents angered at extended work hours. Hurt J.
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psnet.ahrq.gov/issue/medical-misdiagnoses-can-have-fatal-consequences
July 27, 2011 - Newspaper/Magazine Article
Medical misdiagnoses can have fatal consequences.
Citation Text:
Medical misdiagnoses can have fatal consequences. Olsen D. State Journal-Register. June 26, 2011.
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psnet.ahrq.gov/issue/patients-get-power-fast-response
March 23, 2009 - Newspaper/Magazine Article
Patients get power of fast response.
Citation Text:
Patients get power of fast response. Landro L. Wall Street Journal. September 1, 2009:D2.
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psnet.ahrq.gov/issue/healthcare-cost-and-utilization-project-hcup
December 24, 2008 - Database/Directory
Healthcare Cost and Utilization Project (HCUP).
Citation Text:
Healthcare Cost and Utilization Project (HCUP). Agency for Healthcare Research and Quality.
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psnet.ahrq.gov/issue/medication-safety-key-action-areas
June 27, 2018 - Book/Report
Medication Safety in Key Action Areas.
Citation Text:
Medication Safety in Key Action Areas. Geneva, Switzerland: World Health Organization; 2019.
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psnet.ahrq.gov/issue/alarm-interventions-during-medical-telemetry-monitoring-failure-mode-effects-analysis
March 18, 2010 - Special or Theme Issue
Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis.
Citation Text:
Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis. PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50. …
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psnet.ahrq.gov/issue/ahrq-challenge-innovative-solutions-update-or-re-create-teamstepps-videos
December 24, 2008 - Press Release/Announcement
AHRQ Challenge on Innovative Solutions To Update or Re-Create TeamSTEPPS Videos.
Citation Text:
AHRQ Challenge on Innovative Solutions To Update or Re-Create TeamSTEPPS Videos. Rockville, MD; Agency for Healthcare Research and Quality: April 2022.
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psnet.ahrq.gov/issue/care-transitions-know-how-not-just-clinicians
May 09, 2018 - Newspaper/Magazine Article
Care transitions know-how not just for clinicians.
Citation Text:
Care transitions know-how not just for clinicians. Ready T. HealthLeaders Media. September 26, 2017.
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psnet.ahrq.gov/issue/hospital-acquired-infections-pennsylvania
December 06, 2006 - Government Resource
Hospital-acquired Infections in Pennsylvania.
Citation Text:
Hospital-acquired Infections in Pennsylvania. PHC4 Research Briefs. Harrisburg, PA: Pennsylvania Health Care Cost Containment Council; July 2005.
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psnet.ahrq.gov/issue/safe-intrahospital-transport-non-icu-patient-using-standardized-handoff-communication
March 18, 2010 - Newspaper/Magazine Article
Safe intrahospital transport of the non-ICU patient using standardized handoff communication.
Citation Text:
Safe intrahospital transport of the non-ICU patient using standardized handoff communication. PA-PSRS Patient Safety Advisory; Patient Safety Authority.…
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psnet.ahrq.gov/issue/hospitals-find-confession-good-bottom-line
November 23, 2016 - Newspaper/Magazine Article
Hospitals find confession good for the bottom line.
Citation Text:
Hospitals find confession good for the bottom line. Greene J.
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psnet.ahrq.gov/web-mm/no-bp-during-nibp
March 01, 2011 - No BP During NIBP
Citation Text:
Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/49475/psn-pdf
March 01, 2005 - Techno Trip
March 1, 2005
Cook RI. Techno Trip. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/techno-trip
The Case
A 70-year-old woman was admitted to a community hospital after developing confusion and right-sided
weakness. A CT scan of her brain showed an acute subdural hematoma. The hospital arranged a…
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - The Result Stopped Here
June 1, 2004
Astion ML. The Result Stopped Here. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/result-stopped-here
The Case
A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital
for continued wound care and intravenous (IV) antib…
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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - Treatment Challenges After Discharge
November 1, 2010
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
Case Objectives
Understand types and frequencies of adverse events occurring between patient discharge from the
hospital …