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  1. psnet.ahrq.gov/web-mm/say-it-again
    January 31, 2020 - Say It Again Citation Text: Henriksen K, Hall KK. Say It Again. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50930/psn-pdf
    February 21, 2020 - Pharmacist Role in Patient Safety February 21, 2020 Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/pharmacist-role-patient-safety Background: The Evolving Role of the Pharmacist Medication errors are highly pervasive across all settings of care,[1] w…
  3. psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
    May 16, 2022 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital Citation Text: Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
  4. psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
    January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications Citation Text: Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Goo…
  5. psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
    February 24, 2021 - SPOTLIGHT CASE Is the "Surgical Personality" a Threat to Patient Safety? Citation Text: Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citati…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49495/psn-pdf
    December 01, 2005 - Low on the Totem Pole December 1, 2005 Wachter R. Low on the Totem Pole. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/low-totem-pole Case Objectives Understand the concept of authority gradient List steps that can be taken to increase communication across an authority gradient Consider the current cultu…
  7. psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
    October 01, 2013 - New Patient Mistakenly Checked in as Another Citation Text: Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33709/psn-pdf
    July 01, 2011 - What Have We Learned About Safe Inpatient Handovers? March 1, 2011 Kripalani S. What Have We Learned About Safe Inpatient Handovers? PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers Perspective The care of hospitalized patients is marked by numerous tra…
  9. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
    January 01, 2019 - Spotlight Spotlight "Do You Want Everything Done?": Clarifying Code Status Source and Credits • This presentation is based on the December 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus M…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846127/psn-pdf
    March 15, 2023 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists March 15, 2023 Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among- spec…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49554/psn-pdf
    January 01, 2008 - Chemotherapy Extravasation January 1, 2008 Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation The Case A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and her oncologist decided to begin sys…
  12. psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
    December 18, 2019 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences Citation Text: Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49529/psn-pdf
    February 01, 2007 - Crossed Coverage February 1, 2007 Kayser SR. Crossed Coverage. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/crossed-coverage The Case A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation evaluation. She had already undergone multiple surgeries, including…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49457/psn-pdf
    September 01, 2004 - Doctor, Don't Treat Thyself September 1, 2004 Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself The Case A 50-year-old radiologist presented to the emergency department of the community hospital where he worked and reported increasing shortnes…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838972/psn-pdf
    October 27, 2022 - The Unhappy Patient Leaves Against Medical Advice. October 27, 2022 Nichols A. The Unhappy Patient Leaves Against Medical Advice. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice The Case A 61-year-old woman was placed on bedrest following major surgery. Her posto…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49763/psn-pdf
    June 01, 2016 - July Syndrome June 1, 2016 Young JQ. July Syndrome. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/july-syndrome The Case A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower lobe lung cancer. The attending surgeon saw the patient along with his fellow,…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49490/psn-pdf
    September 01, 2005 - The Wrong Channel September 1, 2005 Gosbee JW. The Wrong Channel . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/wrong-channel The Case A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial dosing started at 50 mL/hour using a multi-channel medication pump…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49749/psn-pdf
    December 01, 2015 - Hyperglycemia and Switching to Subcutaneous Insulin December 1, 2015 Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin The Case A 47-year-old man with type 2 diabetes was admitted to the hospita…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33733/psn-pdf
    July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes July 1, 2012 Koppel R. Patient Safety and Health Information Technology: Learning from Our Mistakes. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes Perspe…
  20. psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
    June 15, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices Citation Text: Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation …

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