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  1. 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…
  2. 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.…
  3. 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…
  4. 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…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49427/psn-pdf
    January 01, 2004 - Inadvertent Castration January 1, 2004 Calland FJ. Inadvertent Castration. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/inadvertent-castration The Case An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently increased in size. The patient described persisten…
  6. 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…
  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/33745/psn-pdf
    February 01, 2013 - Patient Engagement and Patient Safety February 1, 2013 Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety Perspective Patient engagement has arrived at the station. A Google search of this phrase identified 335,000 hi…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49808/psn-pdf
    October 01, 2017 - High-Risk Medications, High-Risk Transfers October 1, 2017 Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers The Case A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
  10. 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…
  11. 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…
  12. 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…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49655/psn-pdf
    June 01, 2012 - A Painful Dilemma June 1, 2012 Davison SN. A Painful Dilemma. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/painful-dilemma The Case A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
  14. 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…
  15. psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective-case-record-review
    July 20, 2022 - Study Classic Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study. Citation Text: Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospect…
  16. psnet.ahrq.gov/issue/electronic-health-record-based-real-time-analytics-program-patient-safety-surveillance-and
    May 19, 2018 - Study An electronic health record–based real-time analytics program for patient safety surveillance and improvement. Citation Text: Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff …
  17. psnet.ahrq.gov/issue/prescription-opioid-use-misuse-and-use-disorders-us-adults-2015-national-survey-drug-use-and
    October 17, 2012 - Study Classic Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Survey on Drug Use and Health. Citation Text: Han B, Compton WM, Blanco C, et al. Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Surv…
  18. psnet.ahrq.gov/issue/enhancing-teamwork-communication-and-patient-safety-responsiveness-paediatric-intensive-care
    March 10, 2021 - Study Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool. Citation Text: Aldawood F, Kazzaz Y, AlShehri A, et al. Enhancing teamwork communication and patient safety responsiveness in a paediatric inte…
  19. psnet.ahrq.gov/issue/rate-sepsis-hospitalizations-after-misdiagnosis-adult-emergency-department-patients-look
    December 08, 2021 - Study Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system. Citation Text: Horberg MA, Nassery …
  20. psnet.ahrq.gov/issue/high-reliability-organization-framework-health-care-multiyear-implementation-strategy-and
    November 17, 2021 - Study A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes. Citation Text: Sculli GL, Pendley-Louis R, Neily J, et al. A high-reliability organization framework for health care: a multiyear implementation strategy and asso…

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