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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49699/psn-pdf
    February 01, 2014 - Multifactorial Medication Mishap February 1, 2014 Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Id…

  2. Getting the Diagnosis Both Right and Wrong | PSNet

    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. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33702/psn-pdf
    November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH November 1, 2010 In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49760/psn-pdf
    May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49672/psn-pdf
    January 01, 2013 - The Lung Nodule That Refused To Grow December 1, 2012 Balekian AA, Gould MK. The Lung Nodule That Refused To Grow. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/lung-nodule-refused-grow Case Objectives Define a solitary pulmonary nodule. Identify the different initial first steps of management. Identify …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847934/psn-pdf
    April 26, 2023 - Patient Safety Indicators April 26, 2023 Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/patient-safety-indicators Background Over the past 25 years, policymakers and providers, payers, and purchasers of health care have increasingly focused attention on pati…

  7. Medication Mix-Up Leads to Patient Death | PSNet

    psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
    July 08, 2022 - Medication Mix-Up Leads to Patient Death Citation Text: Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX En…

  8. Burnout | PSNet

    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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Do…

  9. Deprescribing as a Patient Safety Strategy | PSNet

    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. Copy Citation Format: Google Scholar BibTeX …

  10. Failure to Rescue | PSNet

    psnet.ahrq.gov/primer/failure-rescue
    September 15, 2024 - Failure to Rescue Citation Text: Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…

  11. Diagnostic Error | PSNet

    psnet.ahrq.gov/curated-library/diagnostic-error
    August 10, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Error  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Karen Cosby, AHRQ Date Created: May 8, …

  12. The Danger of 10% Intravenous Calcium Chloride Extravasation. | PSNet

    psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
    April 24, 2024 - The Danger of 10% Intravenous Calcium Chloride Extravasation. Citation Text: The Danger of 10% Intravenous Calcium Chloride Extravasation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Goog…

  13. When the Indications for Drug Administration Blur | PSNet

    psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
    May 26, 2021 - SPOTLIGHT CASE When the Indications for Drug Administration Blur Citation Text: Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation …

  14. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
    January 01, 2024 - Spotlight Spotlight A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis 1 Source and Credits This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Garth Utter, MD, MSc, FACS…

  15. The Result Stopped Here | PSNet

    psnet.ahrq.gov/web-mm/result-stopped-here
    December 01, 2006 - The Result Stopped Here Citation Text: Astion ML. The Result Stopped Here. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…

  16. Delay in Initiating Antibiotics Results in Fatal Error | PSNet

    psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
    August 02, 2015 - SPOTLIGHT CASE Delay in Initiating Antibiotics Results in Fatal Error Citation Text: Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation …

  17. The Lung Nodule That Refused To Grow | PSNet

    psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
    March 01, 2004 - SPOTLIGHT CASE The Lung Nodule That Refused To Grow Citation Text: Balekian AA, Gould MK. The Lung Nodule That Refused To Grow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Googl…

  18. No News May Not Be Good News | PSNet

    psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
    December 07, 2009 - SPOTLIGHT CASE No News May Not Be Good News Citation Text: Moore CR. No News May Not Be Good News. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  19. SNFs: Opening the Black Box | PSNet

    psnet.ahrq.gov/web-mm/snfs-opening-black-box
    August 27, 2012 - SNFs: Opening the Black Box Citation Text: Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  20. Mismanagement of Delirium | PSNet

    psnet.ahrq.gov/web-mm/mismanagement-delirium
    February 13, 2014 - Mismanagement of Delirium Citation Text: Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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