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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33661/psn-pdf
    December 01, 2007 - Care Transitions December 1, 2007 Kripalani S. Care Transitions. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/care-transitions Perspective Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients pack their belongings and return home. Physicians scratch …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49484/psn-pdf
    June 01, 2005 - Two Pills, Same Drug June 1, 2005 Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/two-pills-same-drug The Case A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past medical history included several AIDS-related complica…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33739/psn-pdf
    October 01, 2012 - The Physical Environment: An Often Unconsidered Patient Safety Tool October 1, 2012 Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool Perspective Now that…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49734/psn-pdf
    May 01, 2015 - Departure From Central Line Ritual May 1, 2015 Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/departure-central-line-ritual The Case A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33625/psn-pdf
    January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions Remain January 1, 2006 Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain Perspective On August 2, 2005, Air France flig…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49493/psn-pdf
    November 01, 2005 - Infused, Not Ingested November 1, 2005 Foley M. Infused, Not Ingested. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/infused-not-ingested The Case A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering contrast, an unfamiliar task for this particular nurse. Rathe…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72693/psn-pdf
    January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33700/psn-pdf
    October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD October 1, 2010 In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0 Editor's note: Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and He…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33823/psn-pdf
    January 01, 2017 - Workplace Safety in Health Care January 1, 2017 Simon RW, Canacari EG. Workplace Safety in Health Care. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/workplace-safety-health-care Perspective The patient safety movement has highlighted the risks that patients face when receiving health care. But, impo…
  10. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.85_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49797/psn-pdf
    June 01, 2017 - Diagnostic Overshadowing Dangers June 1, 2017 Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers The Case A 72-year-old woman with history of opioid abuse was sent to the emergency department (ED) from a methadone clinic because she a…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49436/psn-pdf
    February 26, 2004 - Transfusion "Slip" February 1, 2004 Kaplan HS. Transfusion "Slip". PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/transfusion-slip The Case A married couple, Mr. and Mrs. M, was brought to the emergency department (ED) of a Level 1 trauma center after a half-ton truck that had skidded out of control struck…
  13. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50842/psn-pdf
    January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73999/psn-pdf
    October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …
  16. psnet.ahrq.gov/primer/telehealth-and-patient-safety
    July 27, 2022 - Telehealth and Patient Safety. Citation Text: O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49646/psn-pdf
    February 01, 2012 - Poorly Advanced Directives February 1, 2012 Anderson WG. Poorly Advanced Directives. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/poorly-advanced-directives The Case Cared for at home by his wife and family, an 82-year-old man with multiple chronic medical conditions described his overall health as decli…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49610/psn-pdf
    October 01, 2010 - "Recurrent" Appendicitis October 1, 2010 Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/recurrent-appendicitis The Case An 85-year-old man presented to the emergency department (ED) with right lower quadrant pain. On physical examination, the patient showed rebound t…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49776/psn-pdf
    November 01, 2016 - Continuity Errors in Resident Clinic November 1, 2016 Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic The Case A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty concentrating. …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73515/psn-pdf
    August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents July 28, 2021 https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing- home-residents Summary The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…

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