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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…
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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…
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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…
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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 …
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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…
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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…
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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…
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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…
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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…
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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…
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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.
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For…
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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
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Apri…
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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…
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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 (…
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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…
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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,…
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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…
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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
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - January 19, 2022
A conceptual framework to reduce inpatient preventable deaths.
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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