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  1. psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
    May 01, 2018 - SPOTLIGHT CASE Medication Reconciliation: Whose Job Is It? Citation Text: Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Googl…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33771/psn-pdf
    August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety August 22, 2014 Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety Perspective The frontier of patient safety outside the hospital has y…
  3. psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
    February 26, 2025 - In Conversation With…Christine A. Sinsky, MD February 1, 2016  Citation Text: In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation…
  4. psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
    May 01, 2008 - SPOTLIGHT CASE A Painful Medication Reconciliation Mishap Citation Text: Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google S…
  5. psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
    February 01, 2023 - SPOTLIGHT CASE When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Citation Text: Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49807/psn-pdf
    October 01, 2017 - Translating From Normal to Abnormal October 1, 2017 Turner AM. Translating From Normal to Abnormal. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/translating-normal-abnormal Case Objectives Define limited English proficiency. Understand the principal approaches to machine translation. Review the way mach…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33770/psn-pdf
    August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH August 1, 2014 In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of California, S…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73300/psn-pdf
    July 01, 2022 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care May 26, 2021 https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care Summary The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs,…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49388/psn-pdf
    February 01, 2003 - Unexplained Apnea Under Anesthesia February 1, 2003 Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia Case Objectives Clinical Objectives List the causes of prolonged apnea in the operating room Describe the steps in management …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836885/psn-pdf
    May 16, 2022 - Management of Cardiac Arrest in Unconventional Locations. May 16, 2022 Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations The Case Case #1: An 80-year-old man with history of Parkins…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33720/psn-pdf
    November 01, 2011 - In Conversation With… Eduardo Salas, PhD November 1, 2011 In Conversation With… Eduardo Salas, PhD . PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd Editor's note: Eduardo Salas, PhD, is a University Trustee Chair and Pegasus Professor of Psychology at the University of Ce…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49834/psn-pdf
    July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety July 1, 2018 Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety Case Objectives Unders…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49684/psn-pdf
    May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical Error May 1, 2013 Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error Case Objectives Appreciate that chemotherapy a…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49738/psn-pdf
    August 21, 2015 - Privacy or Safety? August 21, 2015 Halamka JD, McGraw D. Privacy or Safety? PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/privacy-or-safety Case Objectives Understand that the HIPAA Omnibus Rule is an enabler of data sharing, not a barrier. Review common misconceptions about privacy rules. Understand the…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49615/psn-pdf
    December 01, 2010 - The Forgotten Turn December 1, 2010 Barbour S. The Forgotten Turn. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/forgotten-turn Case Objectives Describe the six stages of pressure ulceration per the National Pressure Ulcer Advisory Panel. List risk factors for the development of pressure ulcers in hospita…
  16. psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
    December 01, 2005 - SPOTLIGHT CASE Unexplained Apnea Under Anesthesia Citation Text: Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866343/psn-pdf
    December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency December 31, 2024 Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…
  18. psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
    March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy Citation Text: Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
  19. psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
    February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 26, 2021 Innovation Contact …
  20. psnet.ahrq.gov/web-mm/forgotten-radiographic-read
    June 07, 2016 - The Forgotten Radiographic Read Citation Text: Coil CJ, Witt MD. The Forgotten Radiographic Read. 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 XML EndNote 7…

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