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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73153/psn-pdf
    April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough April 28, 2021 Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough Disclosure of Relev…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49768/psn-pdf
    September 01, 2016 - A Pill Organizing Plight September 1, 2016 McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/pill-organizing-plight Case Objectives Identify patients at high risk for adverse drug events. List drugs that are considered inappropriate in older patients. …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72516/psn-pdf
    November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
  4. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
    January 01, 2022 - Spotlight Spotlight Intraosseous Line Extravasation in a Pediatric Trauma Patient Source and Credits • This presentation is based on the April 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: David Barnes, MD and Joseph Yoon, MD o…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49849/psn-pdf
    January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep January 1, 2019 Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep Case Objectives List the patient safety events that are unique to in…
  6. psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
    February 10, 2021 - SPOTLIGHT CASE A Fatal Twist in Pseudohyperkalemia Citation Text: Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …
  7. psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
    April 27, 2022 - Annual Perspective Annual Perspective: Topics in Medication Safety March 31, 2022  View more articles from the same authors. Citation Text: Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet]. Rockville (MD): Ag…
  8. psnet.ahrq.gov/web-mm/do-me-favor
    September 12, 2016 - Do Me a Favor Citation Text: Williamson A. Do Me a Favor. 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 …
  9. psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
    February 01, 2014 - Wrong-Time Error With High-Alert Medication Citation Text: Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX…
  10. psnet.ahrq.gov/web-mm/routine-goes-awry
    September 23, 2020 - Routine Goes Awry Citation Text: Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50389/psn-pdf
    September 25, 2019 - Getting the Diagnosis Both Right and Wrong September 25, 2019 Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong The Case A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…
  12. psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
    April 24, 2018 - Written Signout: It Only Works If You Use The Right One Citation Text: Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852699/psn-pdf
    August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety August 30, 2023 Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety The COVID-19 pandemic necessitated a shift in operations …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60330/psn-pdf
    May 05, 2020 - Telehealth and Patient Safety During the COVID-19 Response May 14, 2020 Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response Introduction   Telehealth typ…
  15. psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
    January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications Citation Text: Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Goo…
  16. psnet.ahrq.gov/perspective/context-intervention
    August 05, 2020 - The Context Is the Intervention Dr. John Øvretveit | October 1, 2011  View more articles from the same authors. Citation Text: Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
  17. psnet.ahrq.gov/web-mm/allergy-holter
    May 01, 2008 - Allergy to Holter Citation Text: Williams M. Allergy to Holter. 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 …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49458/psn-pdf
    September 01, 2004 - Poor Prognosis September 1, 2004 Lamont EB. Poor Prognosis. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/poor-prognosis Case Objectives Understand the current limitations of physicians' ability to provide prognoses. List the variables that can be used to guide treatment decisions and prognostication in e…
  19. psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
    July 20, 2016 - A Potent Medication Administered in a Not So Viable Route Citation Text: Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: G…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49620/psn-pdf
    February 01, 2011 - Silent Pain in the Neck February 1, 2011 Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/silent-pain-neck The Case A 60-year-old man with no significant past medical history underwent an elective anterior cervical discectomy for persistent right arm weakness due to cervi…

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