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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near- Miss Wrong Transfusion Event January 29, 2020 Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49750/psn-pdf
    January 01, 2016 - A Room Without Orders January 1, 2016 Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/room-without-orders Case Objectives Review a common process for planned direct hospital admissions. Describe challenges of prioritizing day-to-day patient care activities wi…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33692/psn-pdf
    February 01, 2010 - In Conversation with…Thomas J. Nasca, MD February 1, 2010 In Conversation with…Thomas J. Nasca, MD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md Editor's note: Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council fo…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49831/psn-pdf
    June 01, 2018 - Chest Pain in a Rural Hospital June 1, 2018 MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital Case Objectives Recognize that a significant proportion of the Unites States population receives care in rural safety net emergency dep…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33833/psn-pdf
    May 01, 2017 - In Conversation With… David Juurlink, MD, PhD May 1, 2017 In Conversation With… David Juurlink, MD, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd Editor's note: Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of Toronto, w…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33686/psn-pdf
    August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS August 1, 2009 In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms Editor's note: Steven Spear, DBA, MS, MS, is Senior Lecturer at Massachusetts Institute of Tech…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33759/psn-pdf
    October 01, 2012 - Promising Areas for Patient Safety Research December 1, 2003 Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. PSNet [internet]. 2003. https://psnet.ahrq.gov/perspective/promising-areas-patient-safety-research Perspective Setting a Course for Patient Safety Research Although patient safety…
  8. psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
    April 03, 2024 - SPOTLIGHT CASE Medication Reconciliation With a Twist (or Dare We Say, a Patch?) Citation Text: Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
  9. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
    January 01, 2022 - Spotlight Spotlight Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures Source and Credits • This presentation is based on the May 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Kevin Keenan, MD and D…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837215/psn-pdf
    July 08, 2022 - Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. July 8, 2022 Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizure…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49723/psn-pdf
    January 01, 2015 - Monitoring Fetal Health January 1, 2015 Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/monitoring-fetal-health Case Objectives Define fetal heart rate monitoring. Describe the current state of evidence regarding fetal heart rate monitoring. List the known …
  12. psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
    February 22, 2023 - Annual Perspective Improving Diagnostic Safety and Quality Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD | April 26, 2023  View more articles from the same authors. Citation Text: Al-Khafaji J, Lee M, Mossburg S. Improving Di…
  13. psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
    September 01, 2004 - SPOTLIGHT CASE Unintended Consequences of CPOE Citation Text: Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNot…
  14. psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
    February 01, 2011 - The University of Texas System Clinical Safety and Effectiveness Course Eric J. Thomas, MD, MPH; Jan Patterson, MD, MS; Sherry Martin, MEd; Doris Quinn, PhD; Gary Reed, MD; Ken Shine, MD | February 1, 2011  View more articles from the same authors. Citation Text: T…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33831/psn-pdf
    April 01, 2017 - In Conversation With… Mark Chassin, MD, MPP, MPH April 1, 2017 In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph Editor's note: Dr. Chassin is president and chief executive officer of The Joint Commission. He is also p…
  16. psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
    January 13, 2010 - SPOTLIGHT CASE A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis Citation Text: Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
  17. psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
    July 01, 2008 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy Citation Text: Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
  18. psnet.ahrq.gov/web-mm/another-fall
    June 01, 2010 - SPOTLIGHT CASE Another Fall Citation Text: Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848107/psn-pdf
    April 26, 2023 - Improving Diagnostic Safety and Quality April 26, 2023 Al-Khafaji J, Lee M, Mossburg S. Improving Diagnostic Safety and Quality . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality Introduction During an annual editorial review of featured articles in the Agency for …
  20. psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
    April 04, 2018 - SPOTLIGHT CASE The Pains of Chronic Opioid Usage Citation Text: Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google S…

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