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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74253/psn-pdf
    January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic January 12, 2022 Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/patient…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49518/psn-pdf
    August 01, 2006 - It's All in the Syringe August 1, 2006 Weingart SN. It's All in the Syringe. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/its-all-syringe The Case A 33-year-old man with type 2 diabetes presented to his physician's office to discuss his diabetes management. The patient admitted not taking his medications…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33751/psn-pdf
    January 01, 2014 - Strengthening the Business Case for Patient Safety May 1, 2013 Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety Perspective After more than a decade in the national spotlight, the problem of pati…
  4. 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…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49694/psn-pdf
    October 01, 2013 - Are You Mrs. A? An Issue of Identification Over Telephone October 1, 2013 Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone The Case Mr. A was a 78-year-old man admitted with non-ST elevation…
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
    May 01, 2015 - PowerPoint Presentation Spotlight Errors in Sepsis Management This presentation is based on the May 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF) Editor, AHRQ WebM&M: Rober…
  7. psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
    February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3 Citation Text: Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49707/psn-pdf
    April 01, 2014 - CYP450 Drugs: Expect the Unexpected April 1, 2014 Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected The Case A 42-year-old man with acquired immunodeficiency syndrome (AIDS) (CD4 count 198), hip dystocia, and generalized anxiety …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73335/psn-pdf
    May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33700/psn-pdf
    October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD October 1, 2010 In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0 Editor's note: Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and He…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33651/psn-pdf
    June 01, 2007 - In Conversation with...Diane Rydrych, MA June 1, 2007 In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma Editor's Note: Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota Department of Health,…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49538/psn-pdf
    June 01, 2007 - Abnormal Volunteer Results June 1, 2007 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results The Case A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent magnetic resonance imaging (MRI) of her abdo…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49466/psn-pdf
    October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
  14. 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…
  15. psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
    March 01, 2015 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay Citation Text: O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: G…
  16. psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
    April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33762/psn-pdf
    March 01, 2014 - In Conversation With… Alison Holmes, MD, MPH March 1, 2014 In Conversation With… Alison Holmes, MD, MPH. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph Editor's note: Dr. Alison Holmes is Director of Infection Prevention and Control at Imperial College Healthcare NHS …
  18. psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
    September 01, 2005 - Benefits vs. Risks of Intraosseous Vascular Access Citation Text: Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Go…
  19. psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
    February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room Citation Text: Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…
  20. psnet.ahrq.gov/web-mm/collegiality-vs-competence
    August 28, 2024 - Collegiality vs. Competence Citation Text: Sagin T. Collegiality vs. Competence. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…

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