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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - Early in the career of the freshly graduated physician, there are many things to learn and many mistakes
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psnet.ahrq.gov/issue/distractors-obstetric-ultrasound-do-sonographers-have-safety-concerns
March 08, 2023 - Study
Distractors in obstetric ultrasound: do sonographers have safety concerns?
Citation Text:
Najafzadeh A, Woodrow N, Thoirs K. Distractors in obstetric ultrasound: Do sonographers have safety concerns? Australas J Ultrasound Med. 2019;22(3):206-213. doi:10.1002/ajum.12134.
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psnet.ahrq.gov/web-mm/infused-not-ingested
February 01, 2017 - Infused, Not Ingested
Citation Text:
Foley M. Infused, Not Ingested. 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/node/33683/psn-pdf
April 01, 2009 - Accreditation and Regulation: Can They Help Improve
Patient Safety?
April 1, 2009
Warburton RN. Accreditation and Regulation: Can They Help Improve Patient Safety? PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
Perspective
My grandfath…
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psnet.ahrq.gov/web-mm/slippery-slide-life
January 21, 2017 - Help them to see how they will benefit from a new way of doing things.
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psnet.ahrq.gov/node/49825/psn-pdf
April 01, 2018 - interpretation
General Principles
Specific Skills
Check in with the patient to make sure you are getting things
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - Tasks are the "to-do" list, or the
things that need to be completed during cross-coverage.
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psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - Graded autonomy in medical education—managing things that go bump in the
night.
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - rethink, and reorient priorities and approaches to ambulatory care safety in the future. 2 , 3
The more things
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - of 2009 outlined criteria for the meaningful use of health IT systems, which
intended (among other things
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psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
July 10, 2024 - Some things that have surprised us have been the degree of separation of the graduate education programs
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - Often the meeting participants who were involved in providing health care have things they feel are important
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - As patients and families
and as advisors, we’re all working to make things better for the next person
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - Often the meeting participants who were
involved in providing health care have things they feel are
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - Undetected Foreign Object
Citation Text:
Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - Good Catch in the Operating Room
Citation Text:
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - Delayed Management of Necrotizing Soft Tissue Infection
– Who does the Patient Belong To?
April 29, 2020
Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the
Patient Belong To? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tiss…
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - SNFs: Opening the Black Box
December 1, 2013
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/snfs-opening-black-box
The Case
An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a
small bowel obstructio…
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psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - Patient and Family Roles in Safety
June 14, 2023
Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety
Moving From Engagement to Partnership
Involving patients and families in healthcare decisions about patient c…
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - SPOTLIGHT CASE
The Wrong Shot: Error Disclosure
Citation Text:
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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