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psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - Management of Cardiac Arrest in Unconventional
Locations.
May 16, 2022
Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
The Case
Case #1: An 80-year-old man with history of Parkins…
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound
and Patient Safety
July 1, 2018
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
Case Objectives
Unders…
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psnet.ahrq.gov/node/49840/psn-pdf
September 01, 2018 - Steroids and Safety: Preventing Medication Adverse
Events During Transitions of Care
September 1, 2018
Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of
Care. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adver…
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psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - Supervision and Entrustment in Clinical Training:
Protecting Patients, Protecting Trainees
November 1, 2018
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees.
PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-pr…
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
…
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psnet.ahrq.gov/node/49738/psn-pdf
August 21, 2015 - Privacy or Safety?
August 21, 2015
Halamka JD, McGraw D. Privacy or Safety? PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/privacy-or-safety
Case Objectives
Understand that the HIPAA Omnibus Rule is an enabler of data sharing, not a barrier.
Review common misconceptions about privacy rules.
Understand the…
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psnet.ahrq.gov/node/33842/psn-pdf
January 01, 2018 - Assessing the Safety of Electronic Health Records: What
Have We Learned?
September 1, 2017
Sittig DF, Singh H. Assessing the Safety of Electronic Health Records: What Have We Learned? PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
Perspec…
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - Advancing Patient Safety Through State Reporting Systems
Jill Rosenthal, MPH | June 1, 2007
View more articles from the same authors.
Citation Text:
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - SPOTLIGHT CASE
When the Lytes Go Out: A Case of Inpatient Cardiac Arrest
Citation Text:
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . 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/emergent-triage-miss
March 06, 2015 - Emergent Triage Miss
Citation Text:
Travers D. Emergent Triage Miss. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - SPOTLIGHT CASE
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.
Citation Text:
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - Annual Perspective
Annual Perspective: Psychological Safety of Healthcare Staff
March 31, 2022
View more articles from the same authors.
Citation Text:
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…
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psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.
Citation Text:
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - Which Line: Ordering Provider or Proceduralist?
March 1, 2019
Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse…
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?
Citation Text:
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
C…
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures
Citation Text:
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - Missed CANDOR Implementation Opportunities.
November 16, 2022
Schweitzer L. Missed CANDOR Implementation Opportunities. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
The Case
A 58-year-old man with a history of type 2 diabetes mellitus, hypertension, morbid obesit…
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - Missed CANDOR Implementation Opportunities.
Citation Text:
Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Format:
Google Scholar BibTeX EndN…
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psnet.ahrq.gov/node/866995/psn-pdf
October 30, 2024 - A Cognitive and Communication Blind Spot Contributes
to Permanent Paralysis
October 30, 2024
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
Disclosur…
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psnet.ahrq.gov/perspective/suicide-prevention
March 24, 2025 - In these busy healthcare environments, what are some ways that providers can integrate suicide risk screening