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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49765/psn-pdf
    August 21, 2016 - Cognitive Overload in the ICU August 21, 2016 Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/cognitive-overload-icu Case Objectives Identify the role of cognitive overload—especially interruptions—in compromising quality of care and patient safety. List…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33607/psn-pdf
    September 27, 2022 - Burnout September 27, 2022 Yellowlees P, Rea M. Burnout. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/burnout Originally published in December 2011 by researchers at the University of California, San Francisco. Updated in September 2022 by Peter Yellowlees, MD and Margaret Rea, PhD. PSNet primers are regu…

  3. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia | PSNet

    psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
    August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia Citation Text: Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33766/psn-pdf
    May 01, 2014 - In Conversation With… Didier Pittet, MD, MS May 1, 2014 In Conversation With… Didier Pittet, MD, MS. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms Editor's note: Didier Pittet, MD, MS, is Professor of Medicine and Director of the Infection Control Programme and WHO Co…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49486/psn-pdf
    August 21, 2005 - Impatient Inpatient Dosing August 21, 2005 White RH. Impatient Inpatient Dosing. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/impatient-inpatient-dosing Case Objectives Appreciate the challenges of initiating warfarin therapy in the hospitalized patient Understand the fundamental pharmacology of warfarin…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863308/psn-pdf
    February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy February 28, 2024 Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy The Case A…

  7. Duplicate Insulin Order | PSNet

    psnet.ahrq.gov/web-mm/duplicate-insulin-order
    May 04, 2012 - Duplicate Insulin Order Citation Text: Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  8. In Conversation with...Patrick S. Romano, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
    July 10, 2024 - In Conversation with...Patrick S. Romano, MD, MPH November 1, 2010  Citation Text: In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.In Conversation with...Patrick S. Romano, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74021/psn-pdf
    October 25, 2021 - In Conversation With... Georgia Galanou Luchen, Pharm. D. October 25, 2021 In Conversation With.. Georgia Galanou Luchen, Pharm. D. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d Editor’s Note: Georgia Galanou Luchen, Pharm. D., is the Director of Member Rela…

  10. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. | PSNet

    psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
    June 28, 2023 - SPOTLIGHT CASE Prolonged DKA in Pregnancy: A Case of Communication Breakdown. Citation Text: Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…

  11. Editorial Team | PSNet

    psnet.ahrq.gov/Information/Editor
    April 05, 2025 - Browse Author Resources Meet PSNet's Editorial Team The PSNet editorial team is committed to producing the highest quality patient safety content. The team brings a wealth of experience and deep subject matter expertise in the field, ensuring that PSNet content is accurate, reliable, and…

  12. Verbal Orders and Medication Overrides: A Dangerous Combination | PSNet

    psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
    September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination Citation Text: Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…

  13. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout | PSNet

    psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
    January 22, 2020 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout Citation Text: Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848108/psn-pdf
    April 26, 2023 - The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. April 26, 2023 Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/do…

  15. Errors and Near Misses: What Health Care Could Learn From Aviation | PSNet

    psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
    September 01, 2006 - When will health care pass the orange-wire test? Lancet. 2004;364:1567-1568. [go to PubMed] 6.

  16. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. | PSNet

    psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
    June 24, 2020 - Nutrients July 1, 2008 A virtual breakthrough series collaborative for missed test

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837748/psn-pdf
    August 05, 2022 - Challenges of Diabetes Management and Medication Reconciliation August 5, 2022 Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation The Cases Case #1:  A 53-year-old man…

  18. Chest Pain in a Rural Hospital | PSNet

    psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
    June 02, 2021 - SPOTLIGHT CASE Chest Pain in a Rural Hospital Citation Text: MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar Bi…

  19. Cognitive Overload in the ICU | PSNet

    psnet.ahrq.gov/web-mm/cognitive-overload-icu
    June 01, 2005 - SPOTLIGHT CASE Cognitive Overload in the ICU Citation Text: Patel VL, Buchman TG. Cognitive Overload in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTe…

  20. When Patients and Providers Speak Different Languages | PSNet

    psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
    December 08, 2021 - SPOTLIGHT CASE When Patients and Providers Speak Different Languages Citation Text: Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …
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