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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - In the exercises, pilots learn that the messages that they send—spoken or unspoken—when someone does
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - Some of the characteristics of these organizations send important signals for us to emulate. … workforce for noncompliance without understanding and addressing reasons why overrides may be happening, we send
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - Some of the characteristics of these organizations send important signals for us to emulate. … workforce for noncompliance without understanding and addressing reasons why overrides may be happening, we send
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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical
Record Causing an Accidental Medication Overdose
October 31, 2023
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an
Accidental Medication Overdose. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/weight-and-…
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psnet.ahrq.gov/node/73103/psn-pdf
March 31, 2021 - Other options for this patient would have been to send her to the ED
for further evaluation and potential
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psnet.ahrq.gov/web-mm/preventable-rash
October 01, 2012 - Preventable Rash
Citation Text:
McLean C. Preventable Rash. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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…
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - Empty Handoff
September 1, 2012
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/empty-handoff
The Case
A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a
leg wound. The patient's medical history included chronic…
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psnet.ahrq.gov/node/33730/psn-pdf
June 01, 2012 - In Conversation With… Charles Vincent, MPhil, PhD
June 1, 2012
In Conversation With… Charles Vincent, MPhil, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd
Editor's note: Charles Vincent, MPhil, PhD, a psychologist by training, is one of the world's leading p…
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psnet.ahrq.gov/node/60721/psn-pdf
July 21, 2020 - Anyone can FaceTime or send a Zoom
link or a WebEx link, but having that operational infrastructure … Our model before was to send in nurses and let them hold the hand of the
providers and help them to
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - The Consequences of Miscommunication Regarding a
Possible Artifact
June 30, 2021
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
Disclosure of Relevant Financial Relationships…
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - Delayed Recognition of a Positive Blood Culture
Citation Text:
Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33877/psn-pdf
April 01, 2019 - In Conversation With… Timothy B. McDonald, MD, JD
April 1, 2019
In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
Editor's note: Dr. McDonald is President of the Center for Open and Honest Communication at the
MedStar…
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose
Citation Text:
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
May 11, 2019 - SPOTLIGHT CASE
The Consequences of Miscommunication Regarding a Possible Artifact
Citation Text:
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - If an MTP is activated, the blood bank can send a cooler with blood, FFP, and platelets in the appropriate
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - because I had been made aware the week prior that it was considered a patient privacy violation to send
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psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - We can just send out an email to all our providers
describing these five letters and what they stand
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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - also going to make sure that feedback occurs, so that these actions get
back to the providers who send
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psnet.ahrq.gov/web-mm/empty-handoff
August 01, 2017 - Empty Handoff
Citation Text:
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…