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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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psnet.ahrq.gov/node/50391/psn-pdf
September 25, 2019 - Think Like a Surgeon
September 25, 2019
Cooper Z. Think Like a Surgeon. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/think-surgeon
The Case
A patient with a history of T6 paraplegia due to a motor vehicle accident was brought to the emergency
department due to delirium. He was found to be hypotensive and…
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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)…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Two Wrongs Don't Make a Right (Kidney)
March 1, 2015
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
Case Objectives
Review the current definition of wrong-site surgery.
Describe the incidence of wrong-site surgery, and the…
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…
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psnet.ahrq.gov/web-mm/think-surgeon
December 04, 2024 - Think Like a Surgeon
Citation Text:
Cooper Z. Think Like a Surgeon. 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 R…
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psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner
Save
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A…
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psnet.ahrq.gov/node/60611/psn-pdf
June 24, 2020 - prevention of stroke in patients with atrial fibrillation is 20 mg
a day unless the patient has a calculated
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psnet.ahrq.gov/web-mm/need-eat
February 10, 2021 - power-of-attorney agreed, a PEG tube would have been placed and an optimal enteral feeding prescription calculated
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psnet.ahrq.gov/node/50755/psn-pdf
December 18, 2019 - power-of-attorney agreed, a PEG tube would have been placed and an optimal enteral feeding prescription
calculated
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - implemented for various appropriate electrolyte concentrations, with the total electrolyte composition auto-calculated
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages
Citation Text:
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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psnet.ahrq.gov/node/49673/psn-pdf
December 01, 2012 - A Real Heartache
December 1, 2012
Polevoi SK. A Real Heartache. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/real-heartache
The Case
A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The
pain began at rest, and it radiated to his back and left axilla. He had…
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - Complaints as Safety Surveillance
September 1, 2016
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain
came on sudden…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.85_slideshow.ppt
March 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case March 2005
The Hidden Mystery
Source and Credits
This presentation is based on the March 2005
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Douglas D. Br…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
March 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case March 2005
The Hidden Mystery
Source and Credits
This presentation is based on the March 2005
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Douglas D. Br…
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psnet.ahrq.gov/node/33639/psn-pdf
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Where did your interest in safety come from?
Dr. James Bagian: I don't know …
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - January 15, 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…
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness
Suzanne Beyea, RN, PhD | February 1, 2014
Also Read the Conversations
In Conversation With… Enrico Coiera, MB, BS, PhD
In Conversation With… Richard Kronick, PhD
View more …