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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49703/psn-pdf
    March 01, 2014 - After-Visit Confusion March 1, 2014 Ventres W. After-Visit Confusion. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/after-visit-confusion The Case An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white spots near her tongue. The patient's mother accompanied her …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49492/psn-pdf
    November 01, 2005 - Reconciling Doses November 1, 2005 Federico F. Reconciling Doses. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/reconciling-doses Case Objectives List the steps involved in medication reconciliation. Describe the role of each of the stakeholders in medication reconciliation. Discuss how medication reconc…
  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/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…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846125/psn-pdf
    March 15, 2023 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis March 15, 2023 https://psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels- and-effective Summary …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49523/psn-pdf
    November 01, 2006 - Urinary Retention Dilemma November 1, 2006 Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma The Case Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy (BPH) and urinary hesitancy returned to th…
  7. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
    May 01, 2015 - PowerPoint Presentation Spotlight Errors in Sepsis Management This presentation is based on the May 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF) Editor, AHRQ WebM&M: Rober…
  8. psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
    February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3 Citation Text: Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  9. 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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33782/psn-pdf
    March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? March 1, 2015 Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program Perspective Much…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49517/psn-pdf
    August 01, 2006 - Miscalculated Risk August 1, 2006 Strassels SA. Miscalculated Risk. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/miscalculated-risk The Case A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2- week-old infant. He received Vicodin (hydrocodone and a…
  12. psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
    February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error Citation Text: Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …
  13. psnet.ahrq.gov/web-mm/or-peeping
    May 01, 2015 - OR Peeping Citation Text: Mackenzie CF. OR Peeping. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33762/psn-pdf
    March 01, 2014 - In Conversation With… Alison Holmes, MD, MPH March 1, 2014 In Conversation With… Alison Holmes, MD, MPH. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph Editor's note: Dr. Alison Holmes is Director of Infection Prevention and Control at Imperial College Healthcare NHS …
  15. psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
    September 01, 2005 - Benefits vs. Risks of Intraosseous Vascular Access Citation Text: Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Go…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49718/psn-pdf
    January 01, 2015 - Too Much, Too Fast September 1, 2014 Tuot D. Too Much, Too Fast. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/too-much-too-fast The Case A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for fever, tachycardia, and increased respiratory secretions. H…
  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/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. …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33699/psn-pdf
    August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers August 1, 2010 Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers Perspective Academic medical…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49604/psn-pdf
    June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…

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