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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49577/psn-pdf
    January 01, 2009 - Are Two Insulin Pumps Better Than One? January 1, 2009 Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one The Case A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass graft surge…
  2. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
    February 01, 2014 - PowerPoint Presentation Spotlight Case Multifactorial Medication Mishap 1 This presentation is based on the February 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Annie Yang, PharmD, BCPS NYU Langone Medical Center Editor, AHRQ WebM&M: Robe…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49477/psn-pdf
    April 01, 2005 - Hold the tPA April 1, 2005 Fagan SC. Hold the tPA. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hold-tpa The Case A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49590/psn-pdf
    January 01, 2010 - Is the Admission Drug Dose Too Low? August 1, 2009 Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low The Case A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to the hospit…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867980/psn-pdf
    March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls March 25, 2025 Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls. PSNet [internet]. 2025. https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49428/psn-pdf
    January 01, 2004 - To Resuscitate or Not? January 1, 2004 Wu AW, Pronovost P. To Resuscitate or Not? PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/resuscitate-or-not The Case A critically ill end-stage AIDS patient was hospitalized for end-of-life care. Given the state of his disease, his code status was Do Not Resuscitate/…
  7. psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
    February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL February 26, 2025 Innovation Contact …
  8. psnet.ahrq.gov/Webmm/submit-case-info
    August 10, 2025 - Selection Criteria and Honorarium Information How it works Health care professionals may submit de-identified cases that highlight medical errors or other patient safety/quality issues. Note that you can choose to submit cases either …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867845/psn-pdf
    February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary February 26, 2025 https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation- summary Summary This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33681/psn-pdf
    March 01, 2009 - The Role of Health Literacy in Patient Safety March 1, 2009 Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety Perspective Clear health communication is increasingly recognized as essential for promoting …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33579/psn-pdf
    September 15, 2024 - Systems Approach September 15, 2024 Systems Approach. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/systems-approach PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33593/psn-pdf
    June 15, 2024 - Measurement of Patient Safety June 15, 2024 Measurement of Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/measurement-patient-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient …
  13. psnet.ahrq.gov/primer/missed-nursing-care
    September 15, 2024 - Missed Nursing Care Citation Text: Missed Nursing Care. 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 PubMedId RIS …
  14. psnet.ahrq.gov/primer/opioid-safety
    December 15, 2024 - Opioid Safety Citation Text: Opioid Safety. 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 PubMedId RIS Download Ci…
  15. psnet.ahrq.gov/primer/measurement-patient-safety
    September 15, 2024 - Measurement of Patient Safety Citation Text: Measurement of Patient Safety. 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 Pu…
  16. psnet.ahrq.gov/primer/health-care-associated-infections
    December 15, 2024 - Healthcare-associated Infections Citation Text: Healthcare - Associated Infections. 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 t…
  17. psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
    March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008  View more articles from the same authors. Citation Text: Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33565/psn-pdf
    September 01, 2024 - Healthcare-associated Infections June 15, 2024 Healthcare - Associated Infections. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/health-care-associated-infections PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice …
  19. psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
    April 01, 2009 - are particularly legitimate and useful for patient safety improvements, while they are less useful in ensuring
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837784/psn-pdf
    August 05, 2022 - many different levels very quickly, but this aspect of making it easy to use, making it reliable, and ensuring

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