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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Right Patient, Wrong Sample
December 1, 2006
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
The Case
A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On
the morning of surgery, the patien…
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psnet.ahrq.gov/node/60865/psn-pdf
August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-
BC-FACHE
August 31, 2020
In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is …
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psnet.ahrq.gov/web-mm/slippery-slide-life
January 21, 2017 - Slippery Slide Into Life
Citation Text:
Halamek LP. Slippery Slide Into Life. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - In Conversation With… Leah Binder, MA, MGA
April 1, 2014
In Conversation With… Leah Binder, MA, MGA. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
Editor's note: Leah Binder is President and CEO of The Leapfrog Group, a national nonprofit
representing employers and oth…
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psnet.ahrq.gov/node/33842/psn-pdf
January 01, 2018 - Assessing the Safety of Electronic Health Records: What
Have We Learned?
September 1, 2017
Sittig DF, Singh H. Assessing the Safety of Electronic Health Records: What Have We Learned? PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
Perspec…
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psnet.ahrq.gov/primer/simulation-training
September 15, 2024 - Simulation Training
Citation Text:
Edward JJ, Nichols A, Bakerjian D. Simulation Training. 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/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.
Citation Text:
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - SPOTLIGHT CASE
False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.
Citation Text:
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Right Patient, Wrong Sample
Citation Text:
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - Mismanagement of Delirium
Citation Text:
Merrilees J, Lee KP. Mismanagement of Delirium. 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/hidden-mystery
December 01, 2011 - SPOTLIGHT CASE
Hidden Mystery
Citation Text:
Brunette DD. Hidden Mystery. 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/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - Simulation Training
March 1, 2023
Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/simulation-training
Originally published in 2014 by researchers at the University of California, San Francisco. Updated in
March 2023, by Jennifer J. Edwards, MS, RN, CHSE…
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psnet.ahrq.gov/node/49579/psn-pdf
March 21, 2009 - All in the History
March 21, 2009
Fee C. All in the History. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/all-history
Case Objectives
Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it
does not apply to transfers to emergency departments from non-acute care faci…
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy
March 10, 2021
In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family
Cente…
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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - Medication Errors in Retail Pharmacies: Wrong Patient,
Wrong Instructions.
July 28, 2021
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
The Case
…
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - The Perils of Cross Coverage
May 1, 2012
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/perils-cross-coverage
Case Objectives
Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and
care transitions.
Describe ed…
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psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
March 01, 2008 - focus on all components of the procedure, including obtaining consent, utilization of proper sterile technique
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psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
August 01, 2012 - So rather than just collecting information, they have to collect information and use a technique, whether
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - unpreventable, but it is possible that with new approaches or the use of a different type of surgical technique