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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49425/psn-pdf
    November 01, 2003 - Misread Label November 1, 2003 Franklin BD. Misread Label. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/misread-label The Case An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine [Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…

  2. Triggers and Trigger Tools | PSNet

    psnet.ahrq.gov/primer/triggers-and-trigger-tools
    September 15, 2024 - Triggers and Trigger Tools Citation Text: Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49658/psn-pdf
    July 01, 2012 - Misleading Complaint July 1, 2012 Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/misleading-complaint The Case A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with complaints of knee problems. The triage nurse docu…

  4. Polypharmacy | PSNet

    psnet.ahrq.gov/web-mm/polypharmacy
    March 01, 2007 - Polypharmacy Citation Text: Guglielmo JB. Polypharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  5. Responding to Patient Safety Events | PSNet

    psnet.ahrq.gov/primer/responding-patient-safety-events
    October 18, 2023 - Responding to Patient Safety Events Citation Text: Shaikh U. Responding to Patient Safety Events. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33854/psn-pdf
    March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety March 1, 2018 Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety Perspective Errors in hospitals remain a major cause of death.(1…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865984/psn-pdf
    May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. May 29, 2024 Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D- dimer. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49795/psn-pdf
    June 01, 2017 - The Perils of Contrast Media June 1, 2017 Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/perils-contrast-media Case Objectives Recognize that contrast media are potentially nephrotoxic. Identify key risk factors for the development of contrast-induced kidne…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33605/psn-pdf
    March 12, 2021 - Medication Administration Errors March 12, 2021 MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/medication-administration-errors Updated in March 2021. Originally published in January 2018 by researchers at the University of California, San Fra…

  10. Emerging Safety Issues in Artificial Intelligence | PSNet

    psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
    February 20, 2019 - Emerging Safety Issues in Artificial Intelligence Robert Challen, MA, MBBS | July 1, 2019  View more articles from the same authors. Citation Text: Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare…

  11. Departure From Central Line Ritual | PSNet

    psnet.ahrq.gov/web-mm/departure-central-line-ritual
    October 13, 2018 - Departure From Central Line Ritual Citation Text: Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndN…

  12. The Missing Suction Tip | PSNet

    psnet.ahrq.gov/web-mm/missing-suction-tip
    January 01, 2006 - SPOTLIGHT CASE The Missing Suction Tip Citation Text: Thomas EJ, Moore FA. The Missing Suction Tip. 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 …

  13. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-471
    December 31, 2024 - January 22, 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, report…

  14. The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis | PSNet

    psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
    February 26, 2025 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Cop…

  15. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary …

  16. "Recurrent" Appendicitis | PSNet

    psnet.ahrq.gov/web-mm/recurrent-appendicitis
    January 15, 2020 - "Recurrent" Appendicitis Citation Text: Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72834/psn-pdf
    March 10, 2021 - Approach to Improving Patient Safety: Communication March 10, 2021 Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication Introduction Each one of the countless necessa…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857260/psn-pdf
    November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! November 30, 2023 Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/when…

  19. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

    psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
    September 24, 2024 - In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement Eric Thomas, Sarah Mossburg, Merton Lee | September 24, 2024  Also Read the Essay View more articles from the same authors. Citatio…

  20. In Conversation with...Mark Chassin, MD, MPP, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
    April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH April 1, 2009  Also Read an Essay Citation Text: In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.In Conversation with...Mark Chassin, MD, MPP, MPH . PSNet [internet]. Rockville (MD): A…
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