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  1. 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…
  2. psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
    February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! Citation Text: Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33877/psn-pdf
    April 01, 2019 - In Conversation With… Timothy B. McDonald, MD, JD April 1, 2019 In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd Editor's note: Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar…
  4. psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
    August 20, 2018 - Buprenorphine and the Medically Ill Patient Citation Text: McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX E…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857259/psn-pdf
    November 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case  An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…
  7. Spotlight Nstemi (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-07/spotlight_nstemi.pdf
    January 01, 2020 - Spotlight The NSTEMI Curbside Consultation Source and Credits • This presentation is based on the July 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Amparo C. Villablanca, MD and Gordon Wong, MD MBA o AHRQ WebM&M Editors …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860050/psn-pdf
    January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. January 4, 2024 Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant The Case A 2-month-old full-term male infant was b…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848109/psn-pdf
    April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride Extravasation. April 26, 2023 The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation The Case A 52-year-old man with a history of lymphoplasmacytic lymph…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49543/psn-pdf
    September 01, 2007 - Medication Reconciliation: Whose Job Is It? September 1, 2007 Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it Case Objectives Appreciate the prevalence and impact of medication discrepancies at times of transition in …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61078/psn-pdf
    October 28, 2020 - Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump October 28, 2020 Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/inpatient-stroke-management…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49799/psn-pdf
    July 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49676/psn-pdf
    February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49531/psn-pdf
    March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33729/psn-pdf
    May 01, 2012 - The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety May 1, 2012 Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49566/psn-pdf
    July 01, 2008 - Today, it is mathematically estimated (estimates are needed since the actual number is so low) that
  18. psnet.ahrq.gov/issue/healthgrades-seventh-annual-patient-safety-american-hospitals-study
    July 02, 2014 - Book/Report HealthGrades Seventh Annual Patient Safety in American Hospitals Study. Citation Text: HealthGrades Seventh Annual Patient Safety in American Hospitals Study. Golden, CO: HealthGrades, Inc.; March 2010. Copy Citation Save Save to your library …
  19. psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
    November 01, 2012 - While no national study has been conducted, Reynolds and colleagues published one of the first credible estimates
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49793/psn-pdf
    May 01, 2017 - Hemolysis Holdup May 1, 2017 Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hemolysis-holdup The Case A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…

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