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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49816/psn-pdf
    January 01, 2018 - A Painful Medication Reconciliation Mishap January 1, 2018 Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap Case Objectives Recognize that substance use disorders are common in patients with acute pain. Understand th…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49741/psn-pdf
    September 01, 2015 - Abdominal Pain in Early Pregnancy September 1, 2015 Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy Case Objectives Recognize when nausea and vomiting in pregnancy is abnormal. Identify the most common causes of non-obstetric a…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865376/psn-pdf
    March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures March 27, 2024 Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
  4. psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
    September 30, 2011 - Safeguarding Diagnostic Testing at the Point of Care Citation Text: Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838855/psn-pdf
    October 27, 2022 - False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. October 27, 2022 Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49633/psn-pdf
    September 01, 2011 - The Safety and Quality of Long Term Care September 1, 2011 Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care Case Objectives Identify commonly reported adverse events in long-term care. Identify two to three challenges…
  7. psnet.ahrq.gov/perspective/conversation-christine-cassel-md
    February 26, 2025 - In Conversation With… Christine Cassel, MD June 1, 2015  Citation Text: In Conversation With… Christine Cassel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…
  8. psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
    March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy Citation Text: Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836841/psn-pdf
    June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission April 7, 2022 https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and- paramedics-provide-home Sum…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49645/psn-pdf
    February 01, 2012 - E-prescribing: E for error? February 1, 2012 Ashton EW. E-prescribing: E for error? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/e-prescribing-e-error Case Objectives Define e-prescribing. Describe ways in which e-prescribing can reduce health care costs. State how commonly prescription errors occur wit…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49642/psn-pdf
    December 01, 2011 - Order Interrupted by Text: Multitasking Mishap December 1, 2011 Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap Case Objectives State the prevalence of mobile devices among clinicians and their common health…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33744/psn-pdf
    February 01, 2013 - In Conversation With… Beverley H. Johnson February 1, 2013 In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient- and Family-…
  13. psnet.ahrq.gov/sites/default/files/2023-03/challenging_case_of_multiple_suicide_attempts_in_a_complex_patient_with_psychiatric_comorbidities.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Suicide Attempts_03.17.2023 FINAL.pptx Spotlight Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33674/psn-pdf
    February 01, 2009 - In Conversation with…Robert M. Wachter, MD October 1, 2008 In Conversation with…Robert M. Wachter, MD. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md Editor's note: At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and Chief of the…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49584/psn-pdf
    April 01, 2009 - EMR Entry Error: Not So Benign April 1, 2009 Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign The Case A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint of shortness of breath. He was …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852808/psn-pdf
    August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication Breakdown. August 30, 2023 Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown Disclosure of Relevant Financial Relationship…
  17. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
    January 01, 2023 - Spotlight Spotlight Prolonged DKA in Pregnancy: A Case of Communication Breakdown Source and Credits • This presentation is based on the August 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarah Marshall, MD and Nina M. …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49573/psn-pdf
    January 01, 2009 - Dangerous Shift November 1, 2008 Patterson ES. Dangerous Shift. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dangerous-shift Case Objectives Review the evidence base on erroneous actions related to shift changes. Understand the limits of standardizing handoffs in preventing errors at shift change. Expla…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33818/psn-pdf
    November 01, 2016 - In Conversation With… Andrew Bindman, MD November 1, 2016 In Conversation With… Andrew Bindman, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-andrew-bindman-md Editor's note: Dr. Bindman was appointed as Director of the Agency for Healthcare Research and Quality (AHRQ) in May 2016. P…

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