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  1. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - Use of a checklist may be an important tool in preventing this type of error.

  2. In Conversation with… Michael Cohen, RPh, MS, ScD (hon) | PSNet

    psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
    April 01, 2006 - Perspectives on Safety Annual Perspective Technology as a Tool

  3. The Impact of Communication on Medication Errors | PSNet

    psnet.ahrq.gov/web-mm/impact-communication-medication-errors
    August 01, 2009 - Strategies to Reduce Medication Errors A complete, accurate, and current medication list is a critical tool

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867672/psn-pdf
    February 26, 2025 - with an even greater sensitivity of 95% for diagnosing diverticulitis.6 This makes it an attractive tool

  5. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations | PSNet

    psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
    September 27, 2023 - with an even greater sensitivity of 95% for diagnosing diverticulitis. 6 This makes it an attractive tool

  6. 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 …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850678/psn-pdf
    June 14, 2023 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration June 14, 2023 https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults- risk-hospital Summary To address a well-documented hospital adverse outco…

  8. Waiting Too Long | PSNet

    psnet.ahrq.gov/web-mm/waiting-too-long
    February 01, 2013 - Waiting Too Long Citation Text: Rosen MA. Waiting Too Long. 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 …

  9. Glucose Roller Coaster | PSNet

    psnet.ahrq.gov/web-mm/glucose-roller-coaster
    February 02, 2022 - Glucose Roller Coaster Citation Text: Sharpe B. Glucose Roller Coaster. 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 PubMed…

  10. The Dropped Lung | PSNet

    psnet.ahrq.gov/web-mm/dropped-lung
    February 06, 2012 - The Dropped Lung Citation Text: Heffner JR. The Dropped Lung. 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 …

  11. The Forgotten Radiographic Read | PSNet

    psnet.ahrq.gov/web-mm/forgotten-radiographic-read
    June 07, 2016 - The Forgotten Radiographic Read Citation Text: Coil CJ, Witt MD. The Forgotten Radiographic Read. 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 EndNote 7…

  12. An Obstructed View | PSNet

    psnet.ahrq.gov/web-mm/obstructed-view
    August 07, 2019 - An Obstructed View Citation Text: Carter J. An Obstructed View. 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 RIS …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49495/psn-pdf
    December 01, 2005 - Low on the Totem Pole December 1, 2005 Wachter R. Low on the Totem Pole. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/low-totem-pole Case Objectives Understand the concept of authority gradient List steps that can be taken to increase communication across an authority gradient Consider the current cultu…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49512/psn-pdf
    May 01, 2006 - Right? Left? Neither! May 1, 2006 Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-left-neither Case Objectives Appreciate the role of Reason's Swiss Cheese Model in medical errors Understand the process of analyzing a single error Provide suggestions for …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33697/psn-pdf
    June 01, 2010 - What Do We Know About Emergency Department Safety? June 1, 2010 Sklar DP, Crandall CS. What Do We Know About Emergency Department Safety? PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety Perspective Emergency medicine has evolved from a location, with var…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49640/psn-pdf
    November 01, 2011 - The Case for Patient Flow Management November 1, 2011 Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/case-patient-flow-management The Case A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse wa…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33649/psn-pdf
    May 01, 2007 - In Conversation with...Sir Liam Donaldson, MD, MSc May 1, 2007 In Conversation with..Sir Liam Donaldson, MD, MSc. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc Editor's Note: Sir Liam Donaldson, MD, MSc, is England's Chief Medical Officer, a post often referre…

  18. Crossing the Borderline | PSNet

    psnet.ahrq.gov/web-mm/crossing-borderline
    June 01, 2022 - Crossing the Borderline Citation Text: Oldham JM. Crossing the Borderline. 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 Pub…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33820/psn-pdf
    December 01, 2016 - In Conversation With... James P. Bagian, MD, PE December 1, 2016 In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe Editor's note: Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the Uni…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61079/psn-pdf
    October 28, 2020 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication October 28, 2020 Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon- …
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