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  1. psnet.ahrq.gov/web-mm/errors-sepsis-management
    November 03, 2015 - SPOTLIGHT CASE Errors in Sepsis Management Citation Text: Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47002/psn-pdf
    April 25, 2018 - Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities (R18). April 25, 2018 Rockville, MD: Agency for Healthcare Research and Quality; April 10, 2018. PA-18-750. https://psnet.ahrq.gov/issue/making-health-care-safer-ambulatory-care-settings-and-long-term-care- facilities-r18 Research …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33787/psn-pdf
    January 01, 2018 - In Conversation With… Maureen Bisognano June 1, 2015 In Conversation With… Maureen Bisognano. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-maureen-bisognano Editor's note: Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement (IHI). We spoke with her about I…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49655/psn-pdf
    June 01, 2012 - A Painful Dilemma June 1, 2012 Davison SN. A Painful Dilemma. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/painful-dilemma The Case A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
  5. psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
    April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH April 1, 2009  Also Read an Essay Citation Text: In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.In Conversation with...Mark Chassin, MD, MPP, MPH . PSNet [internet]. Rockville (MD): A…
  6. psnet.ahrq.gov/periodic-issue/periodic-issue-430
    March 27, 2024 - March 6, 2024 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, …
  7. psnet.ahrq.gov/Webmm
    May 01, 2021 - WebM&M Cases & Commentaries 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. Commentaries are written by…
  8. psnet.ahrq.gov/webmm
    May 01, 2021 - WebM&M Cases & Commentaries 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. Commentaries are written by…
  9. psnet.ahrq.gov/issue/state-starts-project-track-serious-hospital-mistakes
    May 10, 2006 - Newspaper/Magazine Article State starts project to track serious hospital mistakes. Citation Text: Colburn D. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL February 15, 20…
  10. psnet.ahrq.gov/web-mm/dual-therapy-debacle
    February 01, 2007 - Dual Therapy Debacle Citation Text: Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
  11. psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
    April 01, 2009 - Accreditation and Regulation: Can They Help Improve Patient Safety? Rebecca N. Warburton, PhD | April 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Warburton RN. Accreditation and Regulation: Can They Help Improve Pat…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853081/psn-pdf
    August 30, 2023 - In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing August 30, 2023 Sanford K, Schuelke S, Lee M, et al. In Conversation with.. Kathleen Sanford and Sue Schuelke about Virtual Nursing. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schue…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49745/psn-pdf
    October 01, 2015 - Amphotericin Toxicity October 1, 2015 Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/amphotericin-toxicity The Case A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral posaconazole for residual fungal disease. She present…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863308/psn-pdf
    February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy February 28, 2024 Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy The Case A…
  15. psnet.ahrq.gov/issue/what-are-critical-success-factors-team-training-health-care
    March 21, 2017 - Commentary What are the critical success factors for team training in health care? Citation Text: Salas E, Almeida SA, Salisbury M, et al. What are the critical success factors for team training in health care? Jt Comm J Qual Patient Saf. 2009;35(8):398-405. Copy Citation Format: …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865884/psn-pdf
    May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. May 29, 2024 Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…
  17. psnet.ahrq.gov/web-mm/caution-interrupted
    October 01, 2016 - Caution, Interrupted Citation Text: Wears RL. Caution, Interrupted. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49789/psn-pdf
    April 01, 2017 - Engaging Seriously Ill Older Patients in Advance Care Planning April 1, 2017 Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning Case Objectives Define advance care planning an…
  19. psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
    February 01, 2006 - In Conversation with…John Banja, PhD February 1, 2006  Also Read an Essay Citation Text: In Conversation with…John Banja, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Ci…
  20. psnet.ahrq.gov/perspective/care-transitions
    December 01, 2007 - Care Transitions Sunil Kripalani, MD, MSc | December 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Kripalani S. Care Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depart…

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