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psnet.ahrq.gov/node/841306/psn-pdf
December 14, 2022 - Resilient Healthcare and the Safety-I and Safety-II
Frameworks
December 14, 2022
Deutsch ES, Van CM, Mossburg SE. Resilient Healthcare and the Safety-I and Safety-II Frameworks.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
Resilient healthca…
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psnet.ahrq.gov/node/49764/psn-pdf
June 01, 2016 - Communication With Consultants
June 1, 2016
Cohn SL. Communication With Consultants. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/communication-consultants
The Case
A 30-year-old pregnant woman presented to the emergency department (ED) with nausea, headaches, and
fevers. Her laboratory studies were nota…
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psnet.ahrq.gov/node/49499/psn-pdf
December 02, 2020 - An Outpatient 'Zebra'
January 1, 2006
Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/outpatient-zebra
The Case
A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness.
His past medical history included lumbar disc diseas…
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psnet.ahrq.gov/node/33817/psn-pdf
October 01, 2016 - Health Care Data Science for Quality Improvement and
Patient Safety
October 1, 2016
Rajkomar A. Health Care Data Science for Quality Improvement and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
Perspective
Background
Ha…
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psnet.ahrq.gov/node/33657/psn-pdf
September 01, 2007 - Rediscovering the Power of the Surgical M&M
Conference: The M+M Matrix
September 1, 2007
Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
Perspective
There is a slumbe…
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psnet.ahrq.gov/cme
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations A man with a history of prior umbilical hernia repair presented to the emergency department (ED) with abdominal pain and was initially diagnosed with cholelithiasis before being discharged home. However, the next day he returned to …
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psnet.ahrq.gov/web-mm/dropping-new-lows
December 18, 2024 - SPOTLIGHT CASE
Dropping to New Lows
Citation Text:
Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML End…
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psnet.ahrq.gov/node/73553/psn-pdf
July 28, 2021 - In Conversation With... James Augustine, MD
July 28, 2021
In Conversation With.. James Augustine, MD. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-james-augustine-md
Editor’s Note: James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care
Solutions where he p…
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psnet.ahrq.gov/perspective/conversation-james-augustine-md
July 28, 2021 - In Conversation With... James Augustine, MD
July 28, 2021
Also Read the Essay
Citation Text:
In Conversation With.. James Augustine, MD. PSNet [internet]. 2021.In Conversation With... James Augustine, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - Preoperative Complications
(5)
Transfusion Complications
(6)
Transitions
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psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
December 18, 2024 - 10, 2024
Annual Perspective
Communication During Transitions … 27, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - 10, 2024
Annual Perspective
Communication During Transitions … 27, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - evidence-based set of tools to improve communication and
teamwork skills, may facilitate proper handoffs during transitions
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - It is unclear if transitions of care occurred in this case, but patient volume and turnover demands often
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psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - 2017
View More
Related Resources
Handoff tool improves transitions
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psnet.ahrq.gov/node/73434/psn-pdf
June 30, 2021 - of function, as in the present case.3,4
Communication errors can occur in multiple situations but transitions
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psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
October 01, 2015 - However, several potential problems may arise when a patient transitions out of the hospital while continuing
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psnet.ahrq.gov/node/838855/psn-pdf
October 27, 2022 - used appropriately, can help standardize and organize the most crucial aspects of care
during these transitions
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psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-pandemic
October 30, 2024 - February 24, 2022
Patient Safety Innovations
ECHO-Care Transitions
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psnet.ahrq.gov/node/49645/psn-pdf
February 01, 2012 - The sharing of patient care summaries at transitions of care as a requirement for meaningful use
incentives