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  1. psnet.ahrq.gov/web-mm/magnetic-deflection
    November 18, 2016 - The Magnetic Deflection Citation Text: Kanal E. The Magnetic Deflection. 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 XML EndNote 7 XML Endnote tagged PubMe…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865570/psn-pdf
    April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner April 10, 2024 https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive- approach-data Summary North American Partners…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865698/psn-pdf
    April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges April 24, 2024 Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges Introduction Nurses are essential to patient care, and having a…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60746/psn-pdf
    July 29, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy July 29, 2020 Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy The Case A 28-year-old woman arrived at the Emergency Department (ED) complaining o…
  5. psnet.ahrq.gov/web-mm/medication-overdose
    September 01, 2011 - Medication Overdose Citation Text: Kaushal R. Medication Overdose. 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 EndNote 7 XML Endnote tagged PubMedId RI…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49580/psn-pdf
    March 21, 2009 - Medication Reconciliation Victory After an Avoidable Error March 21, 2009 Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error The Case A 91-year-old woman, previously active and indepen…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33694/psn-pdf
    April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010 In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a priva…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49854/psn-pdf
    February 01, 2019 - Diagnostic Failure: The Growing Deficit February 1, 2019 Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit The Case A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49396/psn-pdf
    April 01, 2003 - The 2-Week Itch April 1, 2003 Cohen MR. The 2-Week Itch. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/2-week-itch The Case A 40-year-old woman with bipolar disorder (on trazodone) came to her primary care physician with new urticaria. She received a handwritten prescription for Zyrtec and Atarax. The ha…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33658/psn-pdf
    October 01, 2007 - In Conversation with...David Marx, JD October 1, 2007 In Conversation with..David Marx, JD. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd Editor's Note: An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49572/psn-pdf
    October 01, 2008 - Mistaken Identity October 1, 2008 Hall LW. Mistaken Identity. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/mistaken-identity The Case An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status and a reported fall. After finding tenderness in her left hip, the p…
  12. psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
    January 01, 2024 - and Ulfat Shaikh, MD Managing Editor: Meghan Weyrich, MPH 2 Objectives At the conclusion of this educationalactivity, participants should be able to: Describe the risk factors for intraoperative awareness.
  13. psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
    October 01, 2009 - It had to do with the fact that the ACGME [Accreditation Council for Graduate Medical Education], which … is the certifying arm for physician training programs, took steps to remove the accreditation for the … surgery training program at the hospital because it had more residents than it was allowed. … program, but this demonstrated some of the serious problems that existed in the hospital. … program.
  14. psnet.ahrq.gov/perspective/conversation-charles-ornstein
    October 01, 2009 - It had to do with the fact that the ACGME [Accreditation Council for Graduate Medical Education], which … is the certifying arm for physician training programs, took steps to remove the accreditation for the … surgery training program at the hospital because it had more residents than it was allowed. … program, but this demonstrated some of the serious problems that existed in the hospital. … program.
  15. psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
    February 26, 2025 - There are TeamSTEPPS training programs, which can be amazing, but take time and energy and you need … from the issue of resilience and readiness of the providers, what else have we learned about teamwork trainingprograms and other ways of trying to improve more traditionally defined safety culture?
  16. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
    January 01, 2022 - Editor: Meghan Weyrich, MPH 2 https://psnet.ahrq.gov/webmm Objectives At the conclusion of this educationalactivity, participants should be able to: • Describe the role of intraosseous (IO) vascular access
  17. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
    January 01, 2024 - Editor: Meghan Weyrich, MPH 2 https://psnet.ahrq.gov/webmm Objectives At the conclusion of this educationalactivity, participants should be able to: • Recognize the importance of maintaining sinus rhythm in
  18. psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
    January 01, 2023 - Patricia Poole, PharmD o Managing Editor: Meghan Weyrich, MPH 2 Objectives At the conclusion of this educationalactivity, participants should be able to: • Describe the signs and symptoms of gabapentin toxicity  
  19. psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
    August 01, 2019 - At a minimum, education or training should include medical terminology; the Health Insurance Portability
  20. psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cybersecurity
    March 27, 2024 - State University System of Florida Board of Governors Healthcare Education Medical Professional Liability

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