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psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes
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December 22, 2020
Innovation
Contact
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
Citation Text:
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Form…
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - Pocket Syringe Swap
Citation Text:
Kulli JC. Pocket Syringe Swap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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psnet.ahrq.gov/node/865374/psn-pdf
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and
Challenges
March 27, 2024
Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
Introducti…
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room
Citation Text:
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/web-mm/caution-interrupted
October 01, 2016 - Caution, Interrupted
Citation Text:
Wears RL. Caution, Interrupted. 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/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Patient Identification Errors: A Systems Challenge
Citation Text:
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/hard-swallow
April 26, 2023 - Hard to Swallow
Citation Text:
Driver J. Hard to Swallow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.
Citation Text:
Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
December 21, 2022 - In Conversation with…Troyen A. Brennan, MD, JD, MPH
December 1, 2005
Citation Text:
In Conversation with…Troyen A. Brennan, MD, JD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
…
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
December 01, 2017 - Unexpected Drawbacks of Electronic Order Sets
Citation Text:
McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - The Result Stopped Here
June 1, 2004
Astion ML. The Result Stopped Here. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/result-stopped-here
The Case
A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital
for continued wound care and intravenous (IV) antib…
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psnet.ahrq.gov/node/49446/psn-pdf
August 30, 2021 - Too Tight Control
May 1, 2004
Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/too-tight-control
Case Objectives
Appreciate the advantages and potential complications of intensive insulin therapy in the hospitalized
patient
List hospital-based safeguards available to…
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - Ectopic or Not?
Citation Text:
Givens VM, Lipscomb GH. Ectopic or Not?. 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/other-hand
December 12, 2012 - On the Other Hand
Citation Text:
Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - Patient Safety Indicators
Citation Text:
Tokareva I, Romano P. Patient Safety Indicators.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/node/33566/psn-pdf
September 15, 2024 - Teamwork Training
September 15, 2024
Teamwork Training. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/teamwork-training
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed …
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psnet.ahrq.gov/node/33573/psn-pdf
March 15, 2025 - Disruptive and Unprofessional Behavior
March 15, 2025
Disruptive and Unprofessional Behavior. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current resear…