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psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - Falling Between the Cracks in the Software
Citation Text:
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
April 01, 2008 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
View more articles from the same authors.
Citation Text:
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. Rockville (MD): Agency for Healthcare Resea…
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psnet.ahrq.gov/node/49586/psn-pdf
May 01, 2009 - Vial Mistakes Involving Heparin
May 1, 2009
Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
The Case
A 65-year-old man was admitted to the hospital for an elective left carotid endarterectomy. During the
procedure, the surgeon re…
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psnet.ahrq.gov/web-mm/overriding-considerations
March 09, 2009 - Overriding Considerations
Citation Text:
Holtzman NA. Overriding Considerations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
July 01, 2011 - Getting the (Right) Doctor, Right Away
Citation Text:
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/49709/psn-pdf
May 01, 2014 - Raise the Bar
May 1, 2014
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/raise-bar
The Case
A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The
patient was seen and evaluated by an anesthesiologist who was new to the cente…
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psnet.ahrq.gov/node/841493/psn-pdf
December 14, 2022 - Telehealth and Patient Safety.
December 14, 2022
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/telehealth-and-patient-safety
Background
In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications
techno…
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psnet.ahrq.gov/web-mm/listen-family
April 15, 2015 - Listen to the Family
Citation Text:
Campbell D. Listen to the Family. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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psnet.ahrq.gov/node/865467/psn-pdf
March 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact
on Treatment Preferences
March 27, 2024
Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc…
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Timely diagnosis of esophageal perforation
Citation Text:
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/comanagement-whos-charge
July 01, 2011 - Comanagement: Who's in Charge?
Citation Text:
Cheng HQ. Comanagement: Who's in Charge?. 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/primer/electronic-health-records
March 15, 2025 - Electronic Health Records
Citation Text:
Electronic Health Records. 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/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - A framework for assessing reasoning about controversial end-of-life clinical decisions.
Citation Text:
Fedyk M, Fairman N, Romano PS, et al. A framework for assessing reasoning about controversial end-of-life clinical decisions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality…
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - Maternal Safety
January 31, 2024
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/maternal-safety
Originally published in 2018 by researchers at the University of California, San Francisco. Updated in
February 2024 by Marla Shauer, PhD(c), MSN, CNM, Amy Nichols,…
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psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - 10, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - 27, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - Model of Care: A Hospitalist's View
November 1, 2018
Promoting effective transitions
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - Staggered Sensitivity Results
Citation Text:
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - Failure to Reevaluate
Citation Text:
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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