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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49731/psn-pdf
    April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49637/psn-pdf
    October 01, 2011 - The Dropped "No" October 1, 2011 Johnson AJ. The Dropped "No". PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropped-no The Case A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in his legs. Because the leg swelling was somewhat more pronounced in his…

  3. Hospital Admission Due to High-Dose Methotrexate Drug Interaction | PSNet

    psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
    October 01, 2003 - Hospital Admission Due to High-Dose Methotrexate Drug Interaction Citation Text: Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Cit…

  4. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-473
    March 25, 2025 - March 5, 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, reports, …

  5. Handoffs and Transitions | PSNet

    psnet.ahrq.gov/perspective/handoffs-and-transitions
    February 01, 2007 - Annual Perspective Handoffs and Transitions Niraj Sehgal, MD, MPH | January 22, 2014  View more articles from the same authors. Citation Text: Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

  6. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
    July 01, 2011 - Spotlight Case July 2008 Spotlight Case Watch the Warfarin! 1 2 Source and Credits This presentation is based on the July 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Raman Khanna, MD, and Margaret Fang, MD, MPH; University of California, Sa…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49416/psn-pdf
    September 01, 2003 - Check the Bags September 1, 2003 Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-bags The Case A 50-year-old man with new atrial fibrillation was placed on a diltiazem drip in the emergency department for rate control. After arriving at the cardiac care unit (CCU…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49460/psn-pdf
    September 01, 2004 - Security Lapse September 1, 2004 Mason D. Security Lapse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/security-lapse The Case A medical student learned that the hospital's radiology image library was accessible throughout the university's computer system, meaning that patient x-rays could be viewed in d…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49541/psn-pdf
    August 21, 2007 - Mark My Tooth August 21, 2007 Smith RA. Mark My Tooth. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/mark-my-tooth The Case A 45-year-old healthy man was scheduled to have two teeth extracted for progressive dental caries. The patient underwent the extractions, awoke from the anesthesia, and then realized…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49667/psn-pdf
    October 01, 2012 - Looking for Meds in All the Wrong Places October 1, 2012 Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places The Case A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She went to t…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49692/psn-pdf
    September 01, 2013 - A Picture Speaks 1000 Words September 1, 2013 Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words The Case A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection repair presented with chest p…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50827/psn-pdf
    January 22, 2020 - Becoming a high-reliability organization through shared learning of safety events January 22, 2020 Klenklen J. Patient Saf Qual HCare. December 19, 2019. https://psnet.ahrq.gov/issue/becoming-high-reliability-organization-through-shared-learning-safety-events High reliability organizations consistently examine wha…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867632/psn-pdf
    February 26, 2025 - Instruments for patient safety assessment: a scoping review. February 26, 2025 Nunes E, Sirtoli F, Lima E, et al. Instruments for patient safety assessment: a scoping review. Healthcare. 2024;12(20):2075. doi:10.3390/healthcare12202075. https://psnet.ahrq.gov/issue/instruments-patient-safety-assessment-scoping-rev…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43579/psn-pdf
    October 08, 2014 - Implications of Health Literacy for Public Health: Workshop Summary. October 8, 2014 Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651. https://psnet.ahrq.gov/issue…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60992/psn-pdf
    October 14, 2020 - Another medical malpractice crisis?: Try something different. October 14, 2020 Sage WM, Boothman RC, Gallagher TH. Another medical malpractice crisis?: Try something different. JAMA. 2020;324(14):1395-1396. doi:10.1001/jama.2020.16557. https://psnet.ahrq.gov/issue/another-medical-malpractice-crisis-try-something-d…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47601/psn-pdf
    December 21, 2018 - Clinical decision support in the era of artificial intelligence. December 21, 2018 Shortliffe EH, Sepúlveda MJ. Clinical Decision Support in the Era of Artificial Intelligence. JAMA. 2018;320(21):2199-2200. doi:10.1001/jama.2018.17163. https://psnet.ahrq.gov/issue/clinical-decision-support-era-artificial-intellige…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50652/psn-pdf
    January 01, 2020 - Preventable adverse drug events: descriptive epidemiology. November 13, 2019 Woo SA, Cragg A, Wickham ME, et al. Preventable adverse drug events: Descriptive epidemiology. Br J Clin Pharmacol. 2020;86(2):291-302. doi:10.1111/bcp.14139. https://psnet.ahrq.gov/issue/preventable-adverse-drug-events-descriptive-epidem…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45564/psn-pdf
    October 03, 2017 - Fostering transparency in outcomes, quality, safety, and costs. October 3, 2017 Austin M, McGlynn EA, Pronovost P. Fostering Transparency in Outcomes, Quality, Safety, and Costs. JAMA. 2016;316(16):1661-1662. doi:10.1001/jama.2016.14039. https://psnet.ahrq.gov/issue/fostering-transparency-outcomes-quality-safety-a…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837032/psn-pdf
    May 04, 2022 - The patient's "story": an examination of patient-reported safety incidents in general practice. May 4, 2022 Madden C, Lydon S, Murphy AW, et al. The patient’s “story”: an examination of patient-reported safety incidents in general practice. Fam Pract. 2022;39(6):1095-1102. doi:10.1093/fampra/cmac033. https://psnet…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43129/psn-pdf
    July 23, 2014 - Use of a daily goals checklist for morning ICU rounds: a mixed-methods study. July 23, 2014 Centofanti JE, Duan EH, Hoad NC, et al. Use of a daily goals checklist for morning ICU rounds: a mixed- methods study. Crit Care Med. 2014;42(8):1797-803. doi:10.1097/CCM.0000000000000331. https://psnet.ahrq.gov/issue/use-d…
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