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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49535/psn-pdf
    May 01, 2007 - Production Pressures May 1, 2007 Carayon P. Production Pressures. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/production-pressures The Case A 65-year-old man with bipolar disorder was scheduled for maintenance electroconvulsive therapy (ECT), a procedure he had received dozens of times before. These pro…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49778/psn-pdf
    December 01, 2016 - One Dose, Two Errors December 1, 2016 Filice GA. One Dose, Two Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/one-dose-two-errors The Case A 65-year-old woman was admitted to the intensive care unit (ICU) with severe sepsis and respiratory failure secondary to community-acquired pneumonia. The pati…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33642/psn-pdf
    November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006 In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you become interested…

  4. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps | PSNet

    psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
    April 24, 2018 - The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps Citation Text: Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33853/psn-pdf
    March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN March 1, 2018 In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn Editor's note: Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Ce…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60330/psn-pdf
    May 05, 2020 - Telehealth and Patient Safety During the COVID-19 Response May 14, 2020 Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response Introduction   Telehealth typ…

  7. Routine Goes Awry | PSNet

    psnet.ahrq.gov/web-mm/routine-goes-awry
    September 23, 2020 - Routine Goes Awry Citation Text: Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…

  8. Psn-Pdf (pdf file)

    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…

  9. Baffled by Botulinum Toxin | PSNet

    psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
    July 17, 2024 - Baffled by Botulinum Toxin Citation Text: Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840175/psn-pdf
    November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism. November 16, 2022 Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism The Case A 61-year-old woman presented to …

  11. EMS Perils from Hospital Overcrowding | PSNet

    psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
    November 25, 2020 - EMS Perils from Hospital Overcrowding Citation Text: Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX E…

  12. Hyponatremia Secondary to Home Parenteral Nutrition Error | PSNet

    psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
    May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error Citation Text: Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: …

  13. Pocket Syringe Swap | PSNet

    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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49687/psn-pdf
    August 21, 2013 - Emergency Error August 21, 2013 Symons NRA. Emergency Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/emergency-error Case Objectives State that emergency surgery is high risk and has high mortality. Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of …

  15. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room | PSNet

    psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
    July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room Citation Text: Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…

  16. The Missing Suction Tip | PSNet

    psnet.ahrq.gov/web-mm/missing-suction-tip
    January 01, 2006 - SPOTLIGHT CASE The Missing Suction Tip Citation Text: Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

  17. The Dropped "No" | PSNet

    psnet.ahrq.gov/web-mm/dropped-no
    October 30, 2019 - The Dropped "No" Citation Text: Johnson AJ. The Dropped "No". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  18. Over-the-Counter Oversight | PSNet

    psnet.ahrq.gov/web-mm/over-counter-oversight
    March 21, 2009 - Over-the-Counter Oversight Citation Text: Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…

  19. Hard to Swallow | PSNet

    psnet.ahrq.gov/web-mm/hard-swallow
    April 26, 2023 - Hard to Swallow Citation Text: Driver J. Hard to Swallow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Fire in the Hole!—An OR Fire | PSNet

    psnet.ahrq.gov/web-mm/fire-hole-or-fire
    August 03, 2017 - Fire in the Hole!—An OR Fire Citation Text: Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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