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  1. psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
    February 10, 2021 - SPOTLIGHT CASE A Fatal Twist in Pseudohyperkalemia Citation Text: Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …
  2. psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
    November 01, 2016 - SPOTLIGHT CASE Dying in the Hospital With Advanced Dementia Citation Text: Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Ci…
  3. psnet.ahrq.gov/perspective/evolution-root-cause-analysis
    February 26, 2025 - The Evolution of Root Cause Analysis Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Behrhorst J, Gale B, Van CM. Th…
  4. psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025  Also Read the Essay View more articles from the same authors. Citation T…
  5. psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
    January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice Hardeep Singh, MD, MPH | January 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Singh H. Diagnostic Errors: A New Chapter in Patient Safe…
  6. psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
    March 09, 2022 - SPOTLIGHT CASE Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis Citation Text: Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. …
  7. psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
    January 23, 2017 - SPOTLIGHT CASE The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. Citation Text: Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.. PSNet [internet]. Rockv…
  8. psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
    February 01, 2012 - In one study that examined closed malpractice claims involving trainees, lack of resident supervision
  9. psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
    March 01, 2014 - A variety of interventions have been done or are being examined at the public health level in terms of
  10. psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
    September 01, 2012 - Little research has examined how to get maximum value out of the nurses or how to allow them to shed
  11. psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
    September 01, 2012 - Little research has examined how to get maximum value out of the nurses or how to allow them to shed
  12. psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
    March 01, 2014 - A variety of interventions have been done or are being examined at the public health level in terms of
  13. psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
    February 01, 2012 - In one study that examined closed malpractice claims involving trainees, lack of resident supervision
  14. psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
    February 01, 2014 - Fewer studies have examined what types of interruptions or distractions cause actual errors in clinical
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866621/psn-pdf
    August 28, 2024 - Application of Safety-II Principles August 28, 2024 Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/application-safety-ii-principles Traditional approaches to patient safety have often been reactive rather than proactive, seeki…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49409/psn-pdf
    July 01, 2003 - Feeling No Pain July 1, 2003 Bogner MS. Feeling No Pain. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/feeling-no-pain The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49830/psn-pdf
    May 01, 2018 - Suicide Risk in the Hospital May 1, 2018 Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/suicide-risk-hospital The Case A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder presented to the emergency department (ED)…
  18. 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…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49867/psn-pdf
    July 02, 2019 - Diuretics and Electrolyte Abnormalities July 2, 2019 Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities Case Objectives Recognize that thiazide diuretics can lead to serious adverse events. State how commonly used t…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49841/psn-pdf
    September 01, 2018 - Chemotherapy Administration Safety Standards September 1, 2018 Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards The Case A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…

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