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Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33856/psn-pdfApril 01, 2018 - Patient Safety During Hospital Discharge April 1, 2018 Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge Perspective Patients are admitted to the hospital in the United States 35 million times per year.(1)… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/867652/psn-pdfFebruary 26, 2025 - The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis Introduction Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49853/psn-pdfFebruary 01, 2019 - Adverse Event During Intrahospital Transport February 1, 2019 Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport The Case A 4-year-old boy underwent surgery under general anesthesia for correction o… -
Spotlight Case July 2008 (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.pptJune 01, 2013 - Spotlight Case July 2008 Spotlight Case Emergency Error 1 2 Source and Credits This presentation is based on the June 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London Editor, AHRQ WebM&M: Robe… -
PowerPoint Presentation (ppt file)
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.pptApril 01, 2015 - PowerPoint Presentation Spotlight Dissecting the Presentation * This presentation is based on the April 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Shirley Beng Suat Ooi, MBBS (S'pore), Emergency Medicine Department, National Univers… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/841493/psn-pdfDecember 14, 2022 - Telehealth and Patient Safety. December 14, 2022 O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/telehealth-and-patient-safety Background In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications techno… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/73549/psn-pdfJuly 28, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. July 28, 2021 Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty The Case A 61-year-old male patient weighing 57… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49751/psn-pdfJanuary 01, 2016 - New Patient Mistakenly Checked in as Another January 1, 2016 Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another The Case A 55-year-old man, presented to a primary care physician's office for an initial vis… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49427/psn-pdfJanuary 01, 2004 - Inadvertent Castration January 1, 2004 Calland FJ. Inadvertent Castration. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/inadvertent-castration The Case An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently increased in size. The patient described persisten… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49756/psn-pdfApril 01, 2016 - Lost in Sign Out and Documentation April 1, 2016 Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation The Case A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the emergency physician, … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/865467/psn-pdfMarch 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences March 27, 2024 Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49686/psn-pdfMay 01, 2013 - Don't Use That Port: Insert a PICC May 1, 2013 Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc The Case A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with fever and abdominal pain. A comp… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49596/psn-pdfDecember 01, 2009 - Round-Trip Service December 1, 2009 McGrath MH. Round-Trip Service. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/round-trip-service The Case A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms in his left knee. He was referred by his primary care provid… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49616/psn-pdfDecember 01, 2010 - Milliliters vs. Milligrams December 1, 2010 Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams The Case A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His evaluation showed acu… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49785/psn-pdfFebruary 01, 2017 - Refused Medication Error February 1, 2017 Foley M. Refused Medication Error. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/refused-medication-error The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was alert to self and place only. The patient h… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/33633/psn-pdfMay 01, 2006 - Patient Safety in the Physician Office Setting May 1, 2006 Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting Perspective Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49680/psn-pdfMarch 01, 2013 - Pathologic Mistake March 1, 2013 Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pathologic-mistake The Case A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The discomfort worsened with eating. After losing 15 pounds … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/853772/psn-pdfSeptember 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable September 27, 2023 Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable The Case A fourteen-ye… -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49746/psn-pdfOctober 01, 2015 - An Obstructed View October 1, 2015 Carter J. An Obstructed View. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/obstructed-view The Case A 66-year-old man with a history of benign prostatic hyperplasia and obstructive sleep apnea presented to the emergency department (ED) with subacute abdominal pain that … -
Psn-Pdf (pdf file)
psnet.ahrq.gov/node/49622/psn-pdfMarch 01, 2011 - Dropping the Ball Despite an Integrated EMR March 1, 2011 Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr The Case A patient followed at a community-based clinic that is part of a large health care system with an in…
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