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  1. psnet.ahrq.gov/issue/arrival-ambulance-explains-variation-mortality-time-admission-retrospective-study-admissions
    January 29, 2018 - Study Classic Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England. Citation Text: Anselmi L, Meacock R, Kristensen SR, et al. Arrival by amb…
  2. psnet.ahrq.gov/issue/effect-health-information-exchange-recognition-medication-discrepancies-interrupted-when-data
    November 16, 2022 - Study Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial. Citation Text: Boockvar K, Ho W, Pruskowski J, et al. Effect of health information exchange on recogni…
  3. psnet.ahrq.gov/issue/development-evidence-based-framework-factors-contributing-patient-safety-incidents-hospital
    June 25, 2014 - Review Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. Citation Text: Lawton R, McEachan RRC, Giles SJ, et al. Development of an evidence-based framework of factors contributing to patient safety …
  4. psnet.ahrq.gov/issue/identifying-patient-centred-recommendations-improving-patient-safety-general-practices
    April 25, 2018 - Study Identifying patient-centred recommendations for improving patient safety in General Practices in England: a qualitative content analysis of free-text responses using the Patient Reported Experiences and Outcomes of Safety in Primary Care (PREOS-PC) questionnaire. Citation Text: Ric…
  5. psnet.ahrq.gov/issue/national-incidence-medication-error-surgical-patients-and-after-accreditation-council
    September 23, 2020 - Study National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform. Citation Text: Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients Before and Afte…
  6. psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
    April 26, 2023 - general unit is intermittent vital signs with no way to alert clinicians to deterioration in between assessments
  7. psnet.ahrq.gov/web-mm/or-peeping
    May 01, 2015 - OR Peeping Citation Text: Mackenzie CF. OR Peeping. 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 Dow…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49459/psn-pdf
    September 01, 2004 - Caution, Interrupted September 1, 2004 Wears RL. Caution, Interrupted. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/caution-interrupted The Case A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and neutropenia presented to the emergency department (ED) with …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49472/psn-pdf
    March 01, 2005 - Preventable Rash March 1, 2005 McLean C. Preventable Rash. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/preventable-rash The Case A 35-year-old man with HIV was being followed in an outpatient internal medicine clinic. At a routine visit, screening laboratories were checked. The clinic never contacted th…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72587/psn-pdf
    December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability December 23, 2020 Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49710/psn-pdf
    May 01, 2014 - Discontinued Medications: Are They Really Discontinued? May 1, 2014 Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued The Case A 69-year-old man with a history of chronic atrial f…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49734/psn-pdf
    May 01, 2015 - Departure From Central Line Ritual May 1, 2015 Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/departure-central-line-ritual The Case A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33666/psn-pdf
    October 01, 2008 - Methicillin-Resistant Staphylococcus aureus April 1, 2008 Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus Perspective Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49422/psn-pdf
    November 01, 2003 - 40 of K November 1, 2003 Lesar TS. 40 of K. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/40-k The Case An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72693/psn-pdf
    January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49444/psn-pdf
    May 01, 2004 - Do Me a Favor May 1, 2004 Williamson A. Do Me a Favor. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/do-me-favor The Case A 26-year-old gravida 4 para 1 woman reported that her last menstrual period was 5 weeks prior, and she had a positive home pregnancy test. With a history of one ectopic pregnancy, one…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49466/psn-pdf
    October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
  18. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
    July 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case July 2007 Resuscitation Errors: A Shocking Problem Source and Credits This presentation is based on the July 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available online Commentary by: Benjamin Abella, MD, MPhil, …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49837/psn-pdf
    August 01, 2018 - Abdominal Aortic Aneurysm Screening August 1, 2018 Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening Case Objectives Describe risk factors associated with abdominal aortic aneurysm. Identify patient populations meeting criteria fo…
  20. psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
    December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable Citation Text: Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…

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