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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - A Weighty Mistake
March 1, 2013
Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/weighty-mistake
Case Objectives
Understand factors associated with weight-based dosing medication errors in pediatric populations.
Describe how adoption of computerized provider order entry (CPOE) s…
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - Antibiotics for URI/Sinusitis—A Simple Decision Gone
Bad
April 1, 2008
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
Case Objectives
Understand the indications for antibiotic treatment in …
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psnet.ahrq.gov/node/60172/psn-pdf
March 01, 2021 - Verification Screen That Includes Prominent Patient
Photograph Significantly Reduces Errors Caused by
Orders Placed in Wrong Chart
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-
reduc…
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Advancing Patient Safety Through State Reporting
Systems
June 1, 2007
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
Perspective
Seven years ago, the Institute of Medicine (I…
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psnet.ahrq.gov/node/60745/psn-pdf
October 01, 2020 - Multiple High-Risk Events Involving Workflow for Wasting
of Medications Used by Anesthesia
July 29, 2020
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications
Used by Anesthesia. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involvi…
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psnet.ahrq.gov/node/49567/psn-pdf
September 01, 2008 - Empiric Steroids: the Good, the Bad, and the Ugly
September 1, 2008
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
Case Objectives
Describe appropriate indications for use of steroids.
Appreciate contraindicati…
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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/web-mm/july-syndrome
July 01, 2011 - July Syndrome
Citation Text:
Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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D…
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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/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Getting the Diagnosis Both Right and Wrong
Citation Text:
Olson AP. Getting the Diagnosis Both Right and Wrong. 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/code-blue-where
March 30, 2020 - Code Blue—Where To?
Citation Text:
Adams BD. Code Blue—Where To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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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/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. 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/one-dose-two-errors
September 29, 2017 - One Dose, Two Errors
Citation Text:
Filice GA. One Dose, Two Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
December 15, 2024 - Deprescribing as a Patient Safety Strategy
Citation Text:
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. 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/burnout
November 20, 2024 - Burnout
Citation Text:
Yellowlees P, Rea M. Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Do…
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psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride
Extravasation.
April 26, 2023
The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
The Case
A 52-year-old man with a history of lymphoplasmacytic lymph…
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psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice.
Citation Text:
Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - SPOTLIGHT CASE
Right? Left? Neither!
Citation Text:
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - Check Twice, Transport Once
Citation Text:
DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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