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6801. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50931/psn-pdf
      February 26, 2020 - Timely diagnosis of esophageal perforation February 26, 2020 Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation The Case  A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…

6802. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49773/psn-pdf
      July 01, 2016 - Near Miss With Neonate October 1, 2016 Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/near-miss-neonate The Case A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxy…

6803. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33679/psn-pdf
      January 01, 2009 - Disclosure of Medical Error January 1, 2009 Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/disclosure-medical-error Perspective Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater discl…

6804. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49439/psn-pdf
      March 01, 2004 - Lethal Cap March 1, 2004 Schillinger D. Lethal Cap. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-cap The Case A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…

6805. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
      November 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfusion Overload 1 2 Source and Credits This presentation is based on the November 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …

6806. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49598/psn-pdf
      February 01, 2010 - Medication Reconciliation Pitfalls February 1, 2010 Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls The Case A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was brought to the eme…

6807. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49730/psn-pdf
      April 01, 2015 - Transition to Nowhere April 1, 2015 Farrell TW. Transition to Nowhere. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transition-nowhere The Case A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital …

6808. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33631/psn-pdf
      April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety April 1, 2006 Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…

6809. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49656/psn-pdf
      June 01, 2012 - Comanagement: Who's in Charge? June 1, 2012 Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/comanagement-whos-charge The Case A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left hip fracture to the orthopedic surg…

6810. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49781/psn-pdf
      January 01, 2017 - Hazards of Loading Doses January 1, 2017 Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-loading-doses The Case A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac arrest. Two days after discharg…

6811. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49520/psn-pdf
      September 01, 2006 - DNR in the OR and Afterwards September 1, 2006 Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards The Case An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and suffered a fractured femur. After initial eval…

6812. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33615/psn-pdf
      June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD June 1, 2005 In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd Editor's Note: Peter J. Pronovost, MD, PhD, is Medical Director of the Johns Hopkins Center for Innova…

6813. National Patient Safety Goals | PSNet
      psnet.ahrq.gov/primer/national-patient-safety-goals
      January 16, 2025 - National Patient Safety Goals Citation Text: Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…

6814. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866265/psn-pdf
      July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport July 31, 2024 MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…

6815. In Conversation with…Janet Corrigan, PhD, MBA | PSNet
      psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
      April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010  Also Read an Essay Citation Text: In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

6816. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33858/psn-pdf
      May 01, 2018 - In Conversation With… John Halamka, MD, MS May 1, 2018 In Conversation With… John Halamka, MD, MS. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms Editor's note: Dr. Halamka is the International Healthcare Innovation Professor at Harvard Medical School, Chief Information …

6817. Accreditation and Regulation: Can They Help Improve Patient Safety? | PSNet
      psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
      April 01, 2009 - Second, changes must be evaluated for effectiveness, ideally both before (ex ante evaluation) and after

6818. More than a feeling: the role of empathetic care in promoting safety in health care. | PSNet
      psnet.ahrq.gov/issue/more-feeling-role-empathetic-care-promoting-safety-health-care
      June 23, 2021 - Study More than a feeling: the role of empathetic care in promoting safety in health care. Citation Text: Leana C, Meuris J, Lamberton C. More Than a Feeling: The Role of Empathetic Care in Promoting Safety in Health Care. ILR Review. 2017;71(2):394-425. doi:10.1177/0019793917720432. C…

6819. Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinically actionable diagnoses. | PSNet
      psnet.ahrq.gov/issue/impact-diagnostic-management-team-patient-time-diagnosis-and-percent-accurate-and-clinically
      October 19, 2022 - Study Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinically actionable diagnoses. Citation Text: Brashear J, Mize R, Laposata M, et al. Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinica…

6820. Uptake of quality-related event standards of practice by community pharmacies. | PSNet
      psnet.ahrq.gov/issue/uptake-quality-related-event-standards-practice-community-pharmacies
      November 09, 2016 - Study Uptake of quality-related event standards of practice by community pharmacies. Citation Text: Boyle TA, Bishop A, Overmars C, et al. Uptake of Quality-Related Event Standards of Practice by Community Pharmacies. J Pharm Pract. 2015;28(5):442-9. doi:10.1177/0897190014522066. Copy …