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5601. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33747/psn-pdf
      March 01, 2013 - The Literature on Health Care Simulation Education: What Does It Show? March 1, 2013 Cook DA. The Literature on Health Care Simulation Education: What Does It Show? PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show Perspective The education o…

5602. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49781/psn-pdf
      January 01, 2017 - Hazards of Loading Doses January 1, 2017 Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-loading-doses The Case A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac arrest. Two days after discharg…

5603. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49845/psn-pdf
      October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages October 1, 2018 Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages The Case A 1-month-old preterm infant in the ne…

5604. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49390/psn-pdf
      February 01, 2003 - Flying Object Hits MRI February 1, 2003 Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/flying-object-hits-mri The Case A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an anesthesiologist, the child was receiving…

5605. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49590/psn-pdf
      January 01, 2010 - Is the Admission Drug Dose Too Low? August 1, 2009 Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low The Case A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to the hospit…

5606. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49634/psn-pdf
      September 01, 2011 - Situational (Un)Awareness September 1, 2011 Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/situational-unawareness The Case A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver function tests, including a bi…

5607. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866841/psn-pdf
      September 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary September 23, 2024 https://psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and- intervention-innovation Summary UNC Health is a nonprofit healthcare system of more than 500 clinics and…

5608. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33601/psn-pdf
      December 15, 2024 - Electronic Health Records December 15, 2024 Electronic Health Records. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/electronic-health-records 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 safet…

5609. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/843736/psn-pdf
      February 01, 2023 - Saved by ECMO February 1, 2023 Weiss NA. Saved by ECMO . PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/saved-ecmo The Case A 27-year-old pregnant woman was admitted at an estimated gestational age (EGA) of 29 weeks for increased shortness of breath. She was diagnosed with severe pulmonary arterial hyperte…

5610. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33749/psn-pdf
      April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety? April 1, 2013 Fletcher KE, Reed DA. Are Residency Duty Hour Rules Improving Patient Safety? PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety Perspective Introduction The Accreditation Council f…

5611. Topics | PSNet
      psnet.ahrq.gov/topics-0
      March 03, 2025 - Topics Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Featured Topics in Patient Safety Updated Date: March 3, 2025 …

5612. Fatigue, Sleep Deprivation, and Patient Safety | PSNet
      psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
      September 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety Citation Text: Fatigue, Sleep Deprivation, and Patient Safety. 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 X…

5613. Healthcare-associated Infections | PSNet
      psnet.ahrq.gov/primer/health-care-associated-infections
      December 15, 2024 - Healthcare-associated Infections Citation Text: Healthcare - Associated Infections. 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 Endnote t…

5614. The Soil, Not the Seed: The Real Problem with Root Cause Analysis | PSNet
      psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
      March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008  View more articles from the same authors. Citation Text: Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …

5615. An Outpatient 'Zebra' | PSNet
      psnet.ahrq.gov/web-mm/outpatient-zebra
      January 23, 2020 - An Outpatient 'Zebra' Citation Text: Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

5616. Spotlight (pdf file)
      psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
      January 01, 2024 - • Laboratory testing showed normal white blood cell count of 8,500, but with 1.6% abnormal metamyelocytes

5617. In Conversation With... Cindy Brach | PSNet
      psnet.ahrq.gov/perspective/conversation-cindy-brach
      December 27, 2019 - studies and videos. [24] The success of TeamSTEPPS is well documented in the literature [25] and field testing

5618. In Conversation With… Linda Aiken, PhD, RN | PSNet
      psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
      March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN March 1, 2018  Also Read an Essay Citation Text: In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …

5619. In Conversation with…Peter J. Pronovost, MD, PhD | PSNet
      psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
      June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD June 1, 2005  Also Read an Essay Citation Text: In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…

5620. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. | PSNet
      psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
      July 08, 2022 - SPOTLIGHT CASE A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. Citation Text: Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …