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psnet.ahrq.gov/periodic-issue/periodic-issue-391
April 26, 2023 - May 17, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, a…
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psnet.ahrq.gov/periodic-issue/periodic-issue-395
June 28, 2023 - June 14, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/periodic-issue/periodic-issue-387
April 26, 2023 - April 19, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency
Citation Text:
Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - SPOTLIGHT CASE
Engaging Seriously Ill Older Patients in Advance Care Planning
Citation Text:
Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. 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/periodic-issue/periodic-issue-331
March 31, 2022 - The commentary summarizes the ‘red flag’ symptoms associated with low back pain that should prompt expedited
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psnet.ahrq.gov/periodic-issue/periodic-issue-423
January 04, 2024 - support program (e.g., peer support programs) as well as long-term support for lingering psychological symptoms
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psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - coronary syndrome, 8% have no chest pain at the time of presentation, and up to one-
third have no symptoms
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psnet.ahrq.gov/node/49657/psn-pdf
July 01, 2012 - evaluation of the abdominal pain (to
rule out spontaneous bacterial peritonitis) and to relieve the symptoms
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psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
December 01, 2014 - evaluation of the abdominal pain (to rule out spontaneous bacterial peritonitis) and to relieve the symptoms
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - in favor of anticoagulation include an elevated D-dimer, unprovoked clots, active cancer, or severe symptoms
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - August 5, 2015
Agreement between patient-reported symptoms and their documentation in
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - She reported missing her scheduled hemodialysis session, and her symptoms resolved with prompt inpatient
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - Finally at midnight, the nurse signed out to night shift, mentioning the patient's symptoms and noting
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psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - , asking for basal insulin orders to be written or updated, and telling the nurse immediately about symptoms
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psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
July 21, 2020 - it is important to ensure that prior screening tests do not overtly bias interval evaluation of new symptoms
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - initiated. 1 Rather than following the algorithm, focus was instead diverted to the patient’s neurologic symptoms