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5841. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49742/psn-pdf
      September 01, 2015 - A Fumbled Handoff to Inpatient Rehab September 1, 2015 Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab The Case An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…

5842. Secured But Not Always Safe | PSNet
      psnet.ahrq.gov/web-mm/secured-not-always-safe
      October 01, 2015 - Secured But Not Always Safe Citation Text: Jahr JS, Hosseini P. Secured But Not Always Safe. 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 …

5843. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49814/psn-pdf
      December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation Mishap December 1, 2017 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap The Case A 63-year-old man with a history of coronary…

5844. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49595/psn-pdf
      December 01, 2009 - "Superficial" Report Leads to "Deep" Problem December 1, 2009 Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem The Case A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…

5845. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49406/psn-pdf
      June 01, 2003 - The Dangerous Detour June 1, 2003 Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dangerous-detour The Case Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service for observation after being placed on a 72-hour hold by…

5846. The Forgotten Drip | PSNet
      psnet.ahrq.gov/web-mm/forgotten-drip
      April 01, 2014 - The Forgotten Drip Citation Text: Josephson AS. The Forgotten Drip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

5847. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/857060/psn-pdf
      November 27, 2023 - The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023 Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety Introduction Nurses are a li…

5848. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837785/psn-pdf
      August 05, 2022 - Emergence of Application-based Healthcare August 5, 2022 Marvel FA, Dowell P, Mossburg SE. Emergence of Application-based Healthcare. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/emergence-application-based-healthcare Introduction The demand for digital healthcare, including both telemedicine and hea…

5849. Dual Therapy Debacle | PSNet
      psnet.ahrq.gov/web-mm/dual-therapy-debacle
      February 01, 2007 - Dual Therapy Debacle Citation Text: Kayser SR. Dual Therapy Debacle. 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 Endnote tagged PubMedId …

5850. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49628/psn-pdf
      June 01, 2011 - Routine Goes Awry June 1, 2011 Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/routine-goes-awry The Case A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and scheduled for a tonsillectomy and adenoidectomy. She was in ot…

5851. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33821/psn-pdf
      December 01, 2016 - Errors and Near Misses: What Health Care Could Learn From Aviation December 1, 2016 Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation Perspective Some of the most urg…

5852. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73643/psn-pdf
      August 01, 2022 - ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay August 25, 2021 https://psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled- nursing Summary ECHO-Care Transitions (ECHO-CT) intends to ensure cont…

5853. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49631/psn-pdf
      July 01, 2011 - Patient Safety and Adherence to Self-Administered Medications July 1, 2011 Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications The Case A 30-year-o…

5854. Misread Label | PSNet
      psnet.ahrq.gov/web-mm/misread-label
      August 28, 2024 - Misread Label Citation Text: Franklin BD. Misread Label. 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 XML EndNote 7 XML Endnote tagged PubMedId RIS …

5855. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60653/psn-pdf
      April 25, 2020 - Health Care Delivery and Pharmacists During the COVID- 19 Pandemic June 29, 2020 Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic Medication…

5856. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33698/psn-pdf
      August 01, 2010 - In Conversation with...Richard P. Shannon, MD August 1, 2010 In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the University of Pe…

5857. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49515/psn-pdf
      July 01, 2006 - Over Not So Easy July 1, 2006 Cucina R. Over Not So Easy. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/over-not-so-easy The Case A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On admission, she reported allergies to a number of medications as well as a …

5858. Curated Article Libraries | PSNet
      psnet.ahrq.gov/curated-article-libraries
      March 18, 2025 - Curated Libraries Curated Libraries are groupings of PSNet content, curated by AHRQ and by other experts in the patient safety field. Watch the video to learn more about how this new feature works and how it can be of benefit to you. Latest PSNet…

5859. In Conversation With… Christopher P. Landrigan, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
      April 01, 2013 - For example, performance on cognitive tests ( 1 ) and in laparoscopic surgery skills (measured via simulation

5860. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73104/psn-pdf
      January 04, 2021 - AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety March 30, 2021 Stocking JC, Sandrock C, Fitall E, et al. AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact…