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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
    January 01, 2020 - Spotlight Spotlight Discharged with IV antibiotics: When issues arise, who manages the complications? Source and Credits • This presentation is based on the February 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Monica Donnel…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49785/psn-pdf
    February 01, 2017 - Refused Medication Error February 1, 2017 Foley M. Refused Medication Error. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/refused-medication-error The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was alert to self and place only. The patient h…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33719/psn-pdf
    October 01, 2011 - The Context Is the Intervention October 1, 2011 Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/context-intervention Perspective Introduction What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this context.…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33694/psn-pdf
    April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010 In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a priva…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33629/psn-pdf
    March 01, 2006 - What Does Simulation Add to Teamwork Training? March 1, 2006 Gaba DM. What Does Simulation Add to Teamwork Training? PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training Editor's Note: In these point–counterpoint articles, Drs. Pratt and Sachs of Beth Israel Deacones…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49599/psn-pdf
    February 23, 2010 - Defensive Medicine: "Glowing" with Pain February 1, 2010 Sethi MK. Defensive Medicine: "Glowing" with Pain. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain The Case   A 31-year-old man presented to the emergency department (ED) complaining of abdominal pain and vomiting. The…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49596/psn-pdf
    December 01, 2009 - Round-Trip Service December 1, 2009 McGrath MH. Round-Trip Service. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/round-trip-service The Case A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms in his left knee. He was referred by his primary care provid…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49751/psn-pdf
    January 01, 2016 - New Patient Mistakenly Checked in as Another January 1, 2016 Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another The Case A 55-year-old man, presented to a primary care physician's office for an initial vis…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49782/psn-pdf
    January 01, 2017 - A Potent Medication Administered in a Not So Viable Route January 1, 2017 Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route The Case A 55-year-old man with history of nonischemic cardiomyop…
  10. psnet.ahrq.gov/periodic-issue/periodic-issue-473
    March 25, 2025 - March 5, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49453/psn-pdf
    July 01, 2004 - Bowel Prep July 1, 2004 Nelson D. Bowel Prep. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/bowel-prep The Case The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33856/psn-pdf
    April 01, 2018 - Patient Safety During Hospital Discharge April 1, 2018 Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge Perspective Patients are admitted to the hospital in the United States 35 million times per year.(1)…
  13. psnet.ahrq.gov/web-mm/hold-tpa
    July 29, 2020 - Hold the tPA Citation Text: Fagan SC. Hold the tPA. 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 Dow…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837963/psn-pdf
    August 31, 2022 - Delayed Diagnosis of Mesenteric Ischemia August 31, 2022 Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73553/psn-pdf
    July 28, 2021 - In Conversation With... James Augustine, MD July 28, 2021 In Conversation With.. James Augustine, MD. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-james-augustine-md Editor’s Note: James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he p…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33873/psn-pdf
    February 01, 2019 - In Conversation With… Susan E. Skochelak, MD, PhD February 1, 2019 In Conversation With… Susan E. Skochelak, MD, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd Editor's note: Dr. Skochelak is the Group Vice President for Medical Education at the American Medica…
  17. psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
    April 26, 2023 - Annual Perspective Technology as a Tool for Improving Patient Safety A Jay Holmgren, Susan McBride,Bryan Gale, Sarah Mossburg | March 29, 2023  View more articles from the same authors. Citation Text: Holmgren AJ, McBride S, Gale B, et al. Technology as a …
  18. psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
    July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 29, 2024 View more articles from the same authors. Inno…
  19. psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
    April 04, 2018 - SPOTLIGHT CASE The Pains of Chronic Opioid Usage Citation Text: Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google S…
  20. psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
    October 01, 2004 - SPOTLIGHT CASE Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Citation Text: Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…

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