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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - The Wrong Channel
September 1, 2005
Gosbee JW. The Wrong Channel . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/wrong-channel
The Case
A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial
dosing started at 50 mL/hour using a multi-channel medication pump…
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psnet.ahrq.gov/node/49653/psn-pdf
May 01, 2012 - The Forgotten Line
May 1, 2012
Render ML. The Forgotten Line. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/forgotten-line
The Case
An 81-year-old man with a history of coronary artery disease, hypertension, cerebrovascular accidents, and
chronic kidney disease was transferred to a referral hospital for p…
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - Electronic Err
Citation Text:
Tang PC. Electronic Err. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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…
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psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - Wrong-Time Error With High-Alert Medication
Citation Text:
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. 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/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/850678/psn-pdf
June 14, 2023 - Advance Alert Monitor Program: An Automated Early
Warning System for Adults At Risk for In-Hospital Clinical
Deterioration
June 14, 2023
https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-
risk-hospital
Summary
To address a well-documented hospital adverse outco…
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psnet.ahrq.gov/node/849592/psn-pdf
May 31, 2023 - Preventing Falls Through Patient and Family Engagement
to Create Customized Prevention Plans
May 31, 2023
https://psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-
customized-prevention
Summary
Patient falls in hospitals are common and debilitating adverse events that persis…
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
June 01, 2010 - What Do We Know About Emergency Department Safety?
David P. Sklar, MD; Cameron Crandall, MD | June 1, 2010
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Sklar DP, Crandall CS. What Do We Know About Emergency Department Safety…
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psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
September 01, 2017 - In Conversation With… Andrew Gettinger, MD
September 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Andrew Gettinger, MD. 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/perspective/conversation-didier-pittet-md-ms
May 01, 2014 - In Conversation With… Didier Pittet, MD, MS
May 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Didier Pittet, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. …
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psnet.ahrq.gov/web-mm/round-trip-service
April 26, 2023 - Round-Trip Service
Citation Text:
McGrath MH. Round-Trip Service. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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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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psnet.ahrq.gov/node/33622/psn-pdf
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare
I…
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psnet.ahrq.gov/node/49419/psn-pdf
October 01, 2003 - The Other Side
October 1, 2003
Vincent CA. The Other Side. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/other-side
Case Objectives
List the factors contributing to wrong site surgery.
Understand the key components of the Universal Protocol for eliminating wrong site, wrong
procedure, wrong person surger…
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - SPOTLIGHT CASE
Reconciling Doses
Citation Text:
Federico F. Reconciling Doses. 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/node/49545/psn-pdf
September 01, 2007 - Coming Undone: Failure of Closure Device
September 1, 2007
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
The Case
A 65-year-old man underwent coronary angiography because of atypical exertional chest…
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psnet.ahrq.gov/node/37286/psn-pdf
December 23, 2011 - Different roles, same goal: risk and quality management
partnering for patient safety. By the ASHRM Monographs
Task Force.
December 23, 2011
Bokar V, Perry DG. Different Roles, Same Goal: Risk And Quality Management Partnering For Patient
Safety. By The Ashrm Monographs Task Force.; 2007:17-23, 25. doi:10.1002/jhr…
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psnet.ahrq.gov/node/41094/psn-pdf
January 25, 2012 - Adverse event reporting tool to standardize the reporting
and tracking of adverse events during procedural
sedation: a consensus document from the World SIVA
International Sedation Task Force.
January 25, 2012
Mason KP, Mason KP, Green SM, et al. Adverse event reporting tool to standardize the reporting and
track…
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psnet.ahrq.gov/node/38492/psn-pdf
September 12, 2016 - Practice advisory on anesthetic care for magnetic
resonance imaging: a report by the American Society of
Anesthesiologists Task Force on Anesthetic Care for
Magnetic Resonance Imaging.
September 12, 2016
Practice advisory on anesthetic care for magnetic resonance imaging: an updated report by the american
society…