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psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
February 08, 2023 - Effectiveness and reliability of the four-step STANDING algorithm performed by interns and senior emergency
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psnet.ahrq.gov/node/49824/psn-pdf
March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous
Delay
March 1, 2018
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
The Case
A 35-year-old woman with no prior cardiac history calle…
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psnet.ahrq.gov/node/49393/psn-pdf
April 01, 2003 - Which End Is Which?
April 1, 2003
Campbell AR. Which End Is Which? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/which-end-which
The Case
A 39-year-old woman with chronic peri-anal fistulas and infected anal sinuses underwent laparoscopic
diverting colostomy to divert her fecal stream and allow the perine…
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psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - Comanagement: Who's in Charge?
June 1, 2012
Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/comanagement-whos-charge
The Case
A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left
hip fracture to the orthopedic surg…
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psnet.ahrq.gov/node/49488/psn-pdf
August 21, 2005 - PCA Overdose
August 21, 2005
Doyle JD. PCA Overdose. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pca-overdose
The Case
A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo-
oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
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psnet.ahrq.gov/node/49404/psn-pdf
June 01, 2003 - Not a Miscarriage
June 1, 2003
Learman LA. Not a Miscarriage. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/not-miscarriage
The Case
A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented
at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…
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psnet.ahrq.gov/node/49842/psn-pdf
September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric
Emergency Equipment
September 1, 2018
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet
[internet]. 2018.
https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
The Case
As part of…
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psnet.ahrq.gov/node/49428/psn-pdf
January 01, 2004 - To Resuscitate or Not?
January 1, 2004
Wu AW, Pronovost P. To Resuscitate or Not? PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/resuscitate-or-not
The Case
A critically ill end-stage AIDS patient was hospitalized for end-of-life care. Given the state of his disease,
his code status was Do Not Resuscitate/…
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psnet.ahrq.gov/primer/missed-nursing-care
September 15, 2024 - Missed Nursing Care
Citation Text:
Missed Nursing Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - King, MS Chief of Patient Safety and High Reliability Initiatives Defense Health Agency Department of … George Blike, MD about Surveillance Monitoring
April 26, 2023
Delivering high reliability
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psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
August 01, 2015 - and Health Information Exchange: The Role of Health IT Developers in Improving Patient Safety in High Reliability … Interview
In Conversation with Timothy Vogus about High Reliability
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psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
January 01, 2014 - Interview
In Conversation with Timothy Vogus about High Reliability … Patient Safety
February 26, 2025
Perspective
High Reliability
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psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
November 16, 2022 - Interview
In Conversation with Timothy Vogus about High Reliability … Patient Safety
February 26, 2025
Perspective
High Reliability
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psnet.ahrq.gov/node/60241/psn-pdf
February 24, 2022 - Coronavirus Disease 2019 (COVID-19) and Safety of Older
Adults Residing in Nursing Homes
February 24, 2022
Bakerjian D. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing
Homes. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-…
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psnet.ahrq.gov/web-mm/discharging-our-responsibility
January 16, 2019 - Reliability of heart failure patient care: initial results from the American Heart Association's Get
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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - intervention.4 Frequent nuisance alerts disrupt
the workflow of health professionals and erode trust in the reliability
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability
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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - High reliability
organizations recognize that process variability is the underlying source of failures
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psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - effort is a framework for change on medical/surgical units built around improvements in (i) safety and
reliability
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - intervention. 4 Frequent nuisance alerts disrupt the workflow of health professionals and erode trust in the reliability