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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - Errors in Sepsis Management
May 1, 2015
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/errors-sepsis-management
Case Objectives
Define sepsis, severe sepsis, and septic shock.
Describe the severe sepsis/septic shock resuscitation bundle.
Recognize commonly encou…
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psnet.ahrq.gov/perspective/conversation-christine-cassel-md
February 26, 2025 - In Conversation With… Christine Cassel, MD
June 1, 2015
Citation Text:
In Conversation With… Christine Cassel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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For…
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - The Forgotten Line
Citation Text:
Render ML. The Forgotten Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/49799/psn-pdf
July 01, 2017 - Delayed Recognition of a Positive Blood Culture
July 1, 2017
Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
The Case
A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…
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psnet.ahrq.gov/node/49543/psn-pdf
September 01, 2007 - Medication Reconciliation: Whose Job Is It?
September 1, 2007
Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
Case Objectives
Appreciate the prevalence and impact of medication discrepancies at times of transition in …
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psnet.ahrq.gov/node/33805/psn-pdf
April 01, 2016 - In Conversation With… Thomas J. Nasca, MD, MACP
April 1, 2016
In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
Editor's note: Dr. Nasca is Chief Executive Officer of the Accreditation Council for Graduate Medical
Educat…
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - Tough Call: Addressing Errors From Previous Providers
March 1, 2014
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
Case Objectives
Define what it means to be a professional.
Identi…
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psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - COVID-19: Team and Human Factors to Improve Safety
Citation Text:
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Google Scholar…
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - Spinal Epidural Abscess
Citation Text:
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax
Citation Text:
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - Slow Down: Right Drug, Wrong Formulation
Citation Text:
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/its-sarah-not-stephen
January 01, 2015 - SPOTLIGHT CASE
It's Sarah, Not Stephen!
Citation Text:
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - Personal Health Literacy
Citation Text:
Bakerjian D. Personal Health Literacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - Eptifibatide Epilogue
Citation Text:
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - Communication Failure—Who's in Charge?
Citation Text:
Fackler J, Schwartz JM. Communication Failure—Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - Personal Health Literacy
August 30, 2023
Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/personal-health-literacy
Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in
August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
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psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
November 25, 2020 - Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation
Citation Text:
Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
…
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Mother's Milk, but Whose Mother?
Citation Text:
Dougherty D. Mother's Milk, but Whose Mother?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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