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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49551/psn-pdf
    December 01, 2007 - Too Hot For Comfort December 1, 2007 Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/too-hot-comfort The Case A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV antibiotics via a peripheral line in the left antec…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49850/psn-pdf
    January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia January 1, 2019 Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia The Case A 72-year-old woman with a history of severe peripheral vascular dis…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49449/psn-pdf
    June 01, 2004 - Lethal Vertigo June 1, 2004 Furman JM. Lethal Vertigo. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-vertigo The Case A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and vomiting, without headache. Her initial blood pressure in the emergency departme…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33623/psn-pdf
    December 01, 2005 - The Unintended Consequences of Florida Medical Liability Legislation December 1, 2005 Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation Perspective Quality health …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49628/psn-pdf
    June 01, 2011 - Routine Goes Awry June 1, 2011 Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/routine-goes-awry The Case A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and scheduled for a tonsillectomy and adenoidectomy. She was in ot…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33773/psn-pdf
    September 01, 2014 - Overuse as a Patient Safety Problem September 1, 2014 Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem Perspective Nearly half of primary care physicians in the United States believe that patients cared for in their own prac…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49442/psn-pdf
    May 01, 2004 - Missed TB May 1, 2004 FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/missed-tb The Case A 38-year-old white female with no past medical history presented to the hospital with fevers, respiratory failure, and bilateral pulmonary infiltrates. She was treated empirically w…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49631/psn-pdf
    July 01, 2011 - Patient Safety and Adherence to Self-Administered Medications July 1, 2011 Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications The Case A 30-year-o…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49623/psn-pdf
    March 01, 2011 - Are We Pushing Graduate Nurses Too Fast? March 1, 2011 Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast The Case A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49389/psn-pdf
    February 01, 2003 - Procedural Mishap: Learning Curve? February 1, 2003 Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve The Case A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had undesired fert…
  11. psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
    February 26, 2025 - In Conversation With… Lorri Zipperer, MA November 1, 2015  Citation Text: In Conversation With… Lorri Zipperer, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…
  12. psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
    June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL Apri…
  13. psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
    June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective Zahra Khudeira, PharmD | June 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Khudeira Z. Becoming a Certified Professional in Patient Safet…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836840/psn-pdf
    April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE April 7, 2022 https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and- implements-methods Summary Venous thromboembolism (…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843234/psn-pdf
    January 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. February 1, 2023 Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive D…
  16. psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
    September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up Citation Text: Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867428/psn-pdf
    December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-patricia-dykes-a…
  18. psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
    September 09, 2013 - Double Dose at Transfer May 1, 2012 Surveying care teams after in-hospital deaths
  19. psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
    June 14, 2023 - January 19, 2022 A conceptual framework to reduce inpatient preventable deaths.
  20. psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
    February 26, 2025 - The  To Err Is Human  report  identified deaths occurring in the American health care system because

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