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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49662/psn-pdf
    August 01, 2012 - Wrong Turn through Colon: Misplaced PEG August 1, 2012 Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg The Case An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…
  2. psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
    February 26, 2025 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 31, 2023 Innovation Contact …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849592/psn-pdf
    May 31, 2023 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans May 31, 2023 https://psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create- customized-prevention Summary Patient falls in hospitals are common and debilitating adverse events that persis…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50612/psn-pdf
    October 30, 2019 - The Safety Challenges of Supervision and Night Coverage in Academic Residency October 30, 2019 Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency The Case…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840175/psn-pdf
    November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with Thromboembolism. November 16, 2022 Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism The Case A 61-year-old woman presented to …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50389/psn-pdf
    September 25, 2019 - Getting the Diagnosis Both Right and Wrong September 25, 2019 Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong The Case A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…
  7. psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
    February 24, 2021 - SPOTLIGHT CASE Is the "Surgical Personality" a Threat to Patient Safety? Citation Text: Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citati…
  8. psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
    June 01, 2005 - Diagnostic Failure: The Growing Deficit Citation Text: Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNo…
  9. psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
    December 01, 2012 - In Conversation With… Sharon K. Inouye, MD, MPH December 1, 2012  Also Read an Essay Citation Text: In Conversation With… Sharon K. Inouye, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
  10. psnet.ahrq.gov/periodic-issue/periodic-issue-307
    September 29, 2021 - September 1, 2021 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, repor…
  11. psnet.ahrq.gov/periodic-issue/periodic-issue-350
    July 08, 2022 - July 13, 2022 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, …
  12. psnet.ahrq.gov/issue/distractors-obstetric-ultrasound-do-sonographers-have-safety-concerns
    March 08, 2023 - Study Distractors in obstetric ultrasound: do sonographers have safety concerns? Citation Text: Najafzadeh A, Woodrow N, Thoirs K. Distractors in obstetric ultrasound: Do sonographers have safety concerns? Australas J Ultrasound Med. 2019;22(3):206-213. doi:10.1002/ajum.12134. Copy Cit…
  13. psnet.ahrq.gov/periodic-issue/periodic-issue-467
    December 18, 2024 - December 11, 2024 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, repor…
  14. psnet.ahrq.gov/periodic-issue/periodic-issue-426
    February 28, 2024 - February 7, 2024 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…
  15. psnet.ahrq.gov/periodic-issue/periodic-issue-427
    February 28, 2024 - February 14, 2024 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, repor…
  16. psnet.ahrq.gov/web-mm/wrong-channel
    February 01, 2003 - The Wrong Channel Citation Text: Gosbee JW. The Wrong Channel . 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 RI…
  17. psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
    February 23, 2011 - Patient Identification Errors: A Systems Challenge Citation Text: Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Googl…
  18. psnet.ahrq.gov/web-mm/wheres-feeding-tube
    September 01, 2003 - Where's the Feeding Tube? Citation Text: Metheny NA, Meert KL. Where's the Feeding Tube?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49676/psn-pdf
    February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…

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