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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33609/psn-pdfMarch 15, 2025 - Clinical Decision Support Systems March 15, 2025 Clinical Decision Support Systems. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/clinical-decision-support-systems PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/866205/psn-pdfJuly 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. July 10, 2024 Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hemorrhagic-sh… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33703/psn-pdfNovember 01, 2010 - Are We Getting Better at Measuring Patient Safety? November 1, 2010 Rosen AK. Are We Getting Better at Measuring Patient Safety? PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety Perspective The past decade has witnessed unprecedented interest in patient safe… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73455/psn-pdfJune 30, 2021 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks June 30, 2021 Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks The Case At the… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/861881/psn-pdfJanuary 31, 2024 - In Conversation with...Richard Ricciardi about Office- Based Patient Safety January 31, 2024 Ricciardi R, Lee M, Mossburg S. In Conversation with..Richard Ricciardi about Office-Based Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-pa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/836839/psn-pdfMarch 31, 2022 - Annual Perspective: Psychological Safety of Healthcare Staff March 31, 2022 Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff Introduction The… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/837659/psn-pdfJuly 08, 2022 - Medication Safety Events Related to Diagnostic Imaging July 8, 2022 Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging The Cases Case #1: A 42-year-old woman admitted with… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49531/psn-pdfMarch 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/857259/psn-pdfNovember 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case An 81-year-old man was transferred from an outside hospital and admitted to the intensive car… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865778/psn-pdfMay 29, 2024 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement May 29, 2024 Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-complications-unint… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/854897/psn-pdfOctober 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-… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49402/psn-pdfJune 01, 2003 - Inappropriate Antibiotic Use June 1, 2003 Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use The Case A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a first presentation of s… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73456/psn-pdfJune 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia June 30, 2021 Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49669/psn-pdfNovember 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49639/psn-pdfNovember 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33729/psn-pdfMay 01, 2012 - The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety May 1, 2012 Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/74251/psn-pdfJanuary 26, 2022 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest January 26, 2022 Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022. https… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/72811/psn-pdfSeptember 01, 2022 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Originally published on March 3, 2021 Last updated on March 16, 2021 https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during- initial-treatment Summar… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49705/psn-pdfJanuary 01, 2020 - A "Reflexive" Diagnosis in Primary Care April 1, 2014 Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care Case Objectives Appreciate that primary care doctors may be caring for an increasing number of patients wi… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49663/psn-pdfSeptember 01, 2012 - Peripheral IV in Too Long September 1, 2012 Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long Case Objectives Appreciate the complications associated with peripheral intravenous (IV) catheters. Describe the optimal sterile technique that should be us…
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