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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 5 of 5 Results
WebM&M Case November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip.

Dyrbye LN, Burke SE, Hardeman RR, et al. JAMA. 2018;320:1114-1130.
Physician burnout threatens the well-being and sustainability of the health care workforce. This large prospective cohort study found that 45% of resident physicians experienced burnout. Higher burnout rates were detected in urology, general surgery, emergency medicine, and neurology residents (relative to internal medicine residents). The overall prevalence of burnout was similar to studies of practicing physicians, and significantly higher than studies of the general population. Although most residents were satisfied with their career choice, those who were burned out were more likely to regret their decision to become a physician. An Annual Perspective explored how burnout impacts patient safety.
White RH, Sadeghi B, Tancredi DJ, et al. Med Care. 2009;47.
Postoperative venous thromboembolism is one of several preventable conditions for which hospitals will not receive additional reimbursement from the Centers for Medicare and Medicaid Services. The AHRQ Patient Safety Indicators (PSIs) are intended for use in screening medical records to identify possible safety events. However, this study found that the PSI for postoperative venous thromboembolism lacks sufficient predictive ability to be used as the sole method for detecting cases.
WebM&M Case August 21, 2005
An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding.