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psnet.ahrq.gov/node/49670/psn-pdf
November 01, 2012 - Missed Pneumonia
November 1, 2012
Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/missed-pneumonia
The Case
A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic
chest pain. Review of systems was negative for cough or dy…
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psnet.ahrq.gov/node/33673/psn-pdf
September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety
September 1, 2008
Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
Perspective
Medication safety in hospitals depends on the successful execu…
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - Medical Devices in the "Wild"
December 1, 2014
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medical-devices-wild
The Case
A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes,
chronic pain, arthritis, and…
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psnet.ahrq.gov/node/33775/psn-pdf
December 01, 2014 - African Partnerships for Patient Safety: Lessons Learned
December 1, 2014
Syed SS. African Partnerships for Patient Safety: Lessons Learned. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
Perspective
In the last 6 years I have had the privilege of sha…
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric
Patients at Risk of Physiologic Instability
December 23, 2020
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at
Risk of Physiologic Instability. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm…
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psnet.ahrq.gov/node/851158/psn-pdf
June 28, 2023 - Ventricular Wall Injury during a Diagnostic Cardiac
Catheterization
June 28, 2023
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet].
2023.
https://psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
The Case
A patient was …
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psnet.ahrq.gov/node/49815/psn-pdf
December 01, 2017 - Over-the-Counter Oversight
December 1, 2017
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/over-counter-oversight
The Case
A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although
portions of his skin we…
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psnet.ahrq.gov/node/49718/psn-pdf
January 01, 2015 - Too Much, Too Fast
September 1, 2014
Tuot D. Too Much, Too Fast. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/too-much-too-fast
The Case
A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for
fever, tachycardia, and increased respiratory secretions. H…
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psnet.ahrq.gov/node/49646/psn-pdf
February 01, 2012 - Poorly Advanced Directives
February 1, 2012
Anderson WG. Poorly Advanced Directives. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/poorly-advanced-directives
The Case
Cared for at home by his wife and family, an 82-year-old man with multiple chronic medical conditions
described his overall health as decli…
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces
Hospitalizations Among Nursing Home Residents
July 28, 2021
https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-
home-residents
Summary
The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…
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psnet.ahrq.gov/node/49625/psn-pdf
May 01, 2011 - Pocket Syringe Swap
May 1, 2011
Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/pocket-syringe-swap
The Case
A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for
postoperative pain management. Surgery proceeded uneventfully under…
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psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
April 28, 2021 - Procedural Mishap: Learning Curve?
Citation Text:
Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - Dangerous Dapsone
Citation Text:
Bookwalter T. Dangerous Dapsone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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psnet.ahrq.gov/primer/telehealth-and-patient-safety
July 27, 2022 - Telehealth and Patient Safety.
Citation Text:
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment
Citation Text:
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. 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/miscommunication-or-leads-anticoagulation-mishap
May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap
Citation Text:
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Forma…
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psnet.ahrq.gov/node/50768/psn-pdf
December 27, 2019 - In Conversation With... Cindy Brach
December 27, 2019
In Conversation With.. Cindy Brach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-cindy-brach
Editor’s note: Cindy Brach, MPP is a Senior Healthcare Researcher at the Agency for Healthcare
Research and Quality and is the Co-Chair of th…
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psnet.ahrq.gov/node/49434/psn-pdf
February 01, 2004 - Undiagnosed Vaginal Bleeding
February 1, 2004
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
The Case
The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal
bleeding. Over the past…
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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Check the Anesthesia Machine
Citation Text:
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. 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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