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psnet.ahrq.gov/node/857259/psn-pdf
November 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…
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psnet.ahrq.gov/web-mm/silent-pain-neck
August 19, 2020 - Silent Pain in the Neck
Citation Text:
Bittner EA. Silent Pain in the Neck. 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/harm-alarm-fatigue
February 14, 2018 - SPOTLIGHT CASE
Harm From Alarm Fatigue
Citation Text:
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49669/psn-pdf
November 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.…
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psnet.ahrq.gov/perspective/conversation-christine-cassel-md
February 26, 2025 - In Conversation With… Christine Cassel, MD
June 1, 2015
Citation Text:
In Conversation With… Christine Cassel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/33736/psn-pdf
September 01, 2012 - In Conversation With… Jack Needleman, PhD
September 1, 2012
In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management
at UCLA School of P…
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - SPOTLIGHT CASE
Crossing the Line
Citation Text:
Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/866993/psn-pdf
October 30, 2024 - Some interventions show promise across
multiple substances—for example, prevention strategies like skills-based
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psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
February 26, 2025 - You think about the physician who has advanced knowledge and skills and training trying to wade through
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psnet.ahrq.gov/node/74226/psn-pdf
February 01, 2019 - Resources Used and Skills Needed
VHA support for implementation includes training, technical assistance
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - in Community-Oriented Quality Improvement to
medical students and residents, so that they get those skills
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psnet.ahrq.gov/node/33791/psn-pdf
September 01, 2015 - We need to teach these new types of skills, which is that it's not just the doctor and the patient—it's
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - Selecting local champions
Engaging in baseline data collection and benchmarking
Resources Used and Skills
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psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - world in which patients are managing a lot of
their own care, or nonphysicians with the appropriate skills
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - consequently, they may not buy in to the importance of following the care plan or lack the knowledge or skills
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psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
April 24, 2024 - even on a shift-by-shift basis depending on the availability of other staff and the mix of nursing skills
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - even on a shift-by-shift basis depending on the availability of other staff and the mix of nursing skills
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - EM physicians and general surgeons especially
should strive to master their skills as diagnosticians
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - November 30, 2016
Nurses' perceived skills and attitudes about updated safety concepts
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Sleep deprivation in resident physicians in hospitals has been associated with impaired psychomotor skills