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Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources.
Latest by Clinical Areas
The topic of uncertainty has been largely neglected in the literature despite an understanding that diagnostic reasoning is largely probabilistic. This commentary acknowledges how uncertainty drives... Read More
Cadwallader AB, ed. AMA J Ethics. 2024;26(4):e275-e359.
Drug shortages are a known problem that gained patient safety prominence during the COVID-19 pandemic. This special issue covers a range of systemic considerations toward building the resilience of the medication... Read More
Washington, DC: United States Government Accounting Office; April 11, 2024. Publication GAO-24-106107.
Health care organizations are expected to examine known practice concerns to determine what provider-focused actions need to be undertaken. This report summarizes findings... Read More
Dorset, UK: Health Services Safety Investigations Body; 2024.
The complex health care work environment creates conditions that detract from staff ability to provide safe care. This collection of reports to be developed and distributed over the course of 2024 will cover workforce... Read More
All Clinical Areas (16138)
Back to all filtersA 77-year-old man was admitted for coronary artery bypass graft surgery with aortic valve replacement. The operation went smoothly but the patient went into atrial fibrillation with hypotension during removal of the venous cannula. The patient was shocked at 10 Joules but did not convert to sinus rhythm; the surgeon requested 20 Joules synchronized cardioversion, after which the patient went into ventricular fibrillation and was immediately and successfully defibrillated with 20 Joules.
Dorset, UK: Health Services Safety Investigations Body; 2024.
An elderly patient residing in a group care home, requiring assistance with all activities and having a history of autism-spectrum disorder, experiences fecal leakage issues despite daily medication. During a weekend shift with reduced staffing, a certified nursing assistant (CNA) discovers the patient soiled in bed, necessitating a shower. While attempting to assist the patient, another bowel accident occurs, leading to a fall and head injury when the CNA calls for help.
A 26-year-old man presented to the emergency department (ED) with abdominal pain, displaying tachycardia and extreme agitation. Despite negative findings on physical examination and laboratory tests, his aggressive behavior escalated, necessitating physical and chemical restraint for the safety of both himself and ED staff. The ED physician verbally ordered 10 mg of intramuscular haloperidol, but the primary nurse overrode the automated dispensing unit and mistakenly pulled a vial of midazolam 10 mg instead of haloperidol.
This pair of cases highlight the immediate and long-term consequences of delayed recognition of compartment syndrome, despite patients presenting with symptoms such as severe pain, numbness, and swelling in the affected limbs.
Cadwallader AB, ed. AMA J Ethics. 2024;26(4):e275-e359.
Washington, DC: United States Government Accounting Office; April 11, 2024. Publication GAO-24-106107.
Suicide is the 12th leading cause of death in the United States, and the 3rd leading cause of death for people ages 15-24.1 More than 4% of all emergency department visits are attributed to psychiatric conditions2 and 3–8% of all patients have suicidal ideation when screened in the ED.3 In addition, there are approximately 420,000 ED visits every year for intentional self-harm.4 The emergency department (ED) is an ideal place to implement interventions design
Rockville, MD: Agency for Healthcare Research and Quality: July 2023 - April 2024.
