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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865455/psn-pdf
    March 27, 2024 - Communication During Transitions of Care March 27, 2024 Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/communication-during-transitions-care Introduction Inaccurate or untimely communication and ineffective teamwork in healthca…
  2. 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…
  3. psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
    March 01, 2009 - May I Have Another?—Medication Error Citation Text: Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33607/psn-pdf
    September 27, 2022 - Burnout September 27, 2022 Yellowlees P, Rea M. Burnout. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/burnout Originally published in December 2011 by researchers at the University of California, San Francisco. Updated in September 2022 by Peter Yellowlees, MD and Margaret Rea, PhD. PSNet primers are regu…
  5. 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…
  6. psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
    August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia Citation Text: Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49690/psn-pdf
    September 01, 2013 - The Pains of Chronic Opioid Usage September 1, 2013 Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage Case Objectives Describe the appropriate initial assessment of patients with chronic non-cancer pain. List the most comm…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73642/psn-pdf
    August 25, 2021 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021 Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect- unexpected …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33766/psn-pdf
    May 01, 2014 - In Conversation With… Didier Pittet, MD, MS May 1, 2014 In Conversation With… Didier Pittet, MD, MS. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms Editor's note: Didier Pittet, MD, MS, is Professor of Medicine and Director of the Infection Control Programme and WHO Co…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49474/psn-pdf
    March 01, 2005 - Hidden Mystery March 1, 2005 Brunette DD. Hidden Mystery. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hidden-mystery Case Objectives Appreciate the challenges of caring for morbidly obese patients. List specific interventions that can be implemented when caring for obese patients. Develop a rational ap…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49592/psn-pdf
    October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33651/psn-pdf
    June 01, 2007 - In Conversation with...Diane Rydrych, MA June 1, 2007 In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma Editor's Note: Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota Department of Health,…
  13. psnet.ahrq.gov/perspective/handoffs-and-transitions
    February 01, 2007 - Annual Perspective Handoffs and Transitions Niraj Sehgal, MD, MPH | January 22, 2014  View more articles from the same authors. Citation Text: Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  14. psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
    November 04, 2015 - Patient Safety in the Physician Office Setting Nancy C. Elder, MD, MSPH | May 1, 2006  View more articles from the same authors. Citation Text: Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
  15. psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
    February 01, 2003 - The Unintended Consequences of Florida Medical Liability Legislation Paul Barach, MD, MPH | December 1, 2005  View more articles from the same authors. Citation Text: Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet].…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33661/psn-pdf
    December 01, 2007 - Care Transitions December 1, 2007 Kripalani S. Care Transitions. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/care-transitions Perspective Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients pack their belongings and return home. Physicians scratch …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73335/psn-pdf
    May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49713/psn-pdf
    June 01, 2014 - CVC Removal: A Procedure Like Any Other June 1, 2014 Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other The Case A 27-year-old man with a history of Behçet disease and recurrent liver abscesses was admitted to the hospital for a p…
  19. psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
    September 28, 2022 - Primary Care and Patient Safety: Opportunities at the Interface September 28, 2022  Also Read the Conversations In Conversation With... Freya Spielberg, MD, MPH In Conversation With... Jack Westfall, MD, MPH View more articles from the same authors. …
  20. psnet.ahrq.gov/webmm-case-studies
    March 25, 2025 - WebM&M: Case Studies WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…

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