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  1. psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
    July 17, 2024 - Baffled by Botulinum Toxin Citation Text: Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
  2. psnet.ahrq.gov/web-mm/electronic-err
    April 01, 2014 - Electronic Err Citation Text: Tang PC. Electronic Err. 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 …
  3. psnet.ahrq.gov/web-mm/forgotten-med
    July 01, 2006 - The Forgotten Med Citation Text: Cucina R. The Forgotten Med. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860015/psn-pdf
    September 01, 2024 - Retained Surgical Items: Definition and Epidemiology. January 4, 2024 Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology. PSNet [internet]. 2024. https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology Background Prudent medical practice and federal and state laws r…
  5. psnet.ahrq.gov/web-mm/suicidal-man-gun
    May 01, 2005 - Suicidal Man With Gun Citation Text: Simon RI. Suicidal Man With Gun. 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 tagged PubMedId…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49817/psn-pdf
    January 01, 2018 - Slow Down: Right Drug, Wrong Formulation January 1, 2018 Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation The Case A 65-year-old man presented to his primary care clinic for follow-up after a recent hospitaliz…
  7. psnet.ahrq.gov/web-mm/deciphering-code
    November 16, 2022 - Deciphering the Code Citation Text: Goldstein MK. Deciphering the Code. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
    September 01, 2016 - PowerPoint Presentation Spotlight A Pill Organizing Plight * Source and Credits This presentation is based on the September 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Ro…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73229/psn-pdf
    May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities May 26, 2021 Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850678/psn-pdf
    June 14, 2023 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration June 14, 2023 https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults- risk-hospital Summary To address a well-documented hospital adverse outco…
  11. psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
    April 01, 2010 - SPOTLIGHT CASE Two Wrongs Don't Make a Right (Kidney) Citation Text: DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Schola…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838972/psn-pdf
    October 27, 2022 - The Unhappy Patient Leaves Against Medical Advice. October 27, 2022 Nichols A. The Unhappy Patient Leaves Against Medical Advice. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice The Case A 61-year-old woman was placed on bedrest following major surgery. Her posto…
  13. psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
    April 24, 2024 - Right Electrocardiogram, Wrong Patient Citation Text: Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote…
  14. psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
    January 24, 2018 - Primary Workaround, Secondary Complication Citation Text: Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar B…
  15. psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
    July 02, 2011 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. Citation Text: DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49495/psn-pdf
    December 01, 2005 - Low on the Totem Pole December 1, 2005 Wachter R. Low on the Totem Pole. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/low-totem-pole Case Objectives Understand the concept of authority gradient List steps that can be taken to increase communication across an authority gradient Consider the current cultu…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49638/psn-pdf
    January 01, 2012 - Communication Failure—Who's in Charge? October 1, 2011 Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge The Case A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…
  18. psnet.ahrq.gov/web-mm/chest-tube-complications
    September 27, 2023 - Chest Tube Complications Citation Text: Santhosh L, Broaddus C. Chest Tube Complications. 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 XML EndNote 7 XML End…
  19. psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
    November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012  View more articles from the same authors. Citation Text: Joseph A, Malone EB. The Physical Environment: An Often Unc…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49640/psn-pdf
    November 01, 2011 - The Case for Patient Flow Management November 1, 2011 Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/case-patient-flow-management The Case A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse wa…

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