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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/612828/psn-pdf
    February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications February 23, 2022 Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications Objectives Recognition, early evaluation, and management of kidney …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60168/psn-pdf
    March 25, 2020 - Right Electrocardiogram, Wrong Patient March 25, 2020 Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient The Cases Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49803/psn-pdf
    January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3 August 1, 2017 Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3 The Case A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the app…
  4. psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
    January 01, 2015 - Annual Perspective Patient Safety and Opioid Medications Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2016  View more articles from the same authors. Citation Text: Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. Ro…
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
    June 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case June 2005 Getting to the Root of the Matter Source and Credits This presentation is based on the June 2005 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Scott Flanders, MD; Sa…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49770/psn-pdf
    September 01, 2016 - Wrong-Time Error With High-Alert Medication September 1, 2016 Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication The Case A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
  7. psnet.ahrq.gov/web-mm/urine-tough-position
    January 01, 2009 - Urine a Tough Position Citation Text: Gandhi TK. Urine a Tough Position. 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 PubMe…
  8. psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
    March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety Sara J. Singer, MBA, PhD | September 1, 2013  View more articles from the same authors. Citation Text: Singer SJ. What We've Learned About Leveraging Leadership a…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33834/psn-pdf
    May 22, 2017 - Opioid Overdose as a Patient Safety Problem May 22, 2017 Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem Perspective Opioids serve a valuable role in the treatment of acute pain and pain associat…
  10. psnet.ahrq.gov/web-mm/discharged-blindly
    October 26, 2022 - Discharged Blindly Citation Text: Iezzoni LI. Discharged Blindly. 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…
  11. psnet.ahrq.gov/web-mm/misread-label
    August 28, 2024 - Misread Label Citation Text: Franklin BD. Misread Label. 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 RIS …
  12. psnet.ahrq.gov/web-mm/mark-my-tooth
    June 01, 2014 - Mark My Tooth Citation Text: Smith RA. Mark My Tooth. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS D…
  13. psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
    July 30, 2020 - January 4, 2024 WebM&M Cases A framework for assessing
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60066/psn-pdf
    March 25, 2020 - Some Patients Can't Wait: Improving Timeliness of Emergency Department Care March 25, 2020 Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care D…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74830/psn-pdf
    June 01, 2022 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications February 23, 2022 https://psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-co…
  16. psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
    September 27, 2023 - It is therefore imperative to maintain a high index of suspicion for foreign material when assessing
  17. psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
    January 01, 2008 - Then they have a hard time assessing in a comprehensive way the clinical and operational systems that
  18. psnet.ahrq.gov/issue/systematic-review-and-meta-analysis-effectiveness-pharmacist-led-medication-reconciliation
    January 23, 2017 - Review Systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge. Citation Text: McNab D, Bowie P, Ross A, et al. Systematic review and meta-analysis of the effectiveness of pharmacist-led medication rec…
  19. psnet.ahrq.gov/issue/clinical-diagnoses-and-autopsy-findings-discrepancies-critically-ill-patients
    March 09, 2022 - Study Clinical diagnoses and autopsy findings: discrepancies in critically ill patients. Citation Text: Tejerina E, Esteban A, Fernández-Segoviano P, et al. Clinical diagnoses and autopsy findings: discrepancies in critically ill patients*. Crit Care Med. 2012;40(3):842-6. doi:10.1097/…
  20. psnet.ahrq.gov/issue/harmful-medication-errors-involving-unfractionated-and-low-molecular-weight-heparin-three
    October 23, 2018 - Study Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs. Citation Text: Grissinger MC, Hicks RW, Keroack MA, et al. Harmful medication errors involving unfractionated and low-molecular-weight heparin in three pa…

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