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psnet.ahrq.gov/node/863641/psn-pdf
February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training
February 28, 2024
Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…
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psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
September 01, 2006 - Anesthesia: A Weighty Issue
Citation Text:
Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
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psnet.ahrq.gov/web-mm/situational-unawareness
August 01, 2009 - Situational (Un)Awareness
Citation Text:
Abramson EL, Kaushal R. Situational (Un)Awareness. 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/flying-object-hits-mri
September 01, 2005 - Flying Object Hits MRI
Citation Text:
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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cds.ahrq.gov/sites/default/files/workgroups/33746/CDS_Connect_WG_Summary_September_2021.pdf
January 01, 2021 - September 2021 CDS Connect Work Group Meeting Summary
Clinical Decision Support (CDS) Connect Work Group (WG)
Meeting Summary
September 16, 2021
3:00-4:00 pm ET
Attendees: 33 people, including 4 phone dial-ins
Organization Attendees
AHRQ Sponsors Roland Gamache, Edward Lomotan, Mario Teran (3)
WG M…
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datatools.ahrq.gov/nhqdr/national-quality-strategy-resources/
January 01, 2022 - Skip to main content
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January 01, 2019 - An official website of the Department of Health & Human Services
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…
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psnet.ahrq.gov/node/33694/psn-pdf
April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA
April 1, 2010
In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a
priva…
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psnet.ahrq.gov/node/49465/psn-pdf
December 22, 2021 - Electronic Err
October 1, 2004
Tang PC. Electronic Err. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/electronic-err
The Case
A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest
pain that that had not responded to three sublingual nitroglycerin tablets at…
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psnet.ahrq.gov/node/73549/psn-pdf
July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee
Arthroplasty.
July 28, 2021
Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
The Case
A 61-year-old male patient weighing 57…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…
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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - Inadvertent Castration
January 1, 2004
Calland FJ. Inadvertent Castration. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/inadvertent-castration
The Case
An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently
increased in size. The patient described persisten…
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/node/865467/psn-pdf
March 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact
on Treatment Preferences
March 27, 2024
Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc…
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psnet.ahrq.gov/node/49782/psn-pdf
January 01, 2017 - A Potent Medication Administered in a Not So Viable
Route
January 1, 2017
Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
The Case
A 55-year-old man with history of nonischemic cardiomyop…
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psnet.ahrq.gov/node/49854/psn-pdf
February 01, 2019 - Diagnostic Failure: The Growing Deficit
February 1, 2019
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
The Case
A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…
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psnet.ahrq.gov/node/61080/psn-pdf
October 28, 2020 - Preventing Complications during Aneurysm Clipping –
the Role of Neuromonitoring.
October 28, 2020
DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
…