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  1. psnet.ahrq.gov/web-mm/right-patient-wrong-sample
    June 01, 2004 - Right Patient, Wrong Sample Citation Text: Astion ML. Right Patient, Wrong Sample. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866995/psn-pdf
    October 30, 2024 - A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis October 30, 2024 Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis Disclosur…
  3. psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
    April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest Citation Text: Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…
  4. psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
    February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 26, 2021 Innovation Contact …
  5. psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Andrew P.J. …
  6. psnet.ahrq.gov/perspective/implementing-fall-prevention-program
    November 29, 2023 - Implementing a Fall Prevention Program Frances Healey, RN, PhD | December 1, 2011  View more articles from the same authors. Citation Text: Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
  7. psnet.ahrq.gov/web-mm/signout-fallout
    November 16, 2022 - SPOTLIGHT CASE Signout Fallout Citation Text: Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
  8. psnet.ahrq.gov/web-mm/pregnant-danger
    January 12, 2011 - Pregnant With Danger Citation Text: Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  9. psnet.ahrq.gov/web-mm/mismanagement-delirium
    February 13, 2014 - Mismanagement of Delirium Citation Text: Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
  10. psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
    March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? Citation Text: Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. C…
  11. psnet.ahrq.gov/web-mm/weighing-surgical-safety
    August 04, 2021 - SPOTLIGHT CASE Weighing In on Surgical Safety Citation Text: Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar …
  12. psnet.ahrq.gov/web-mm/duplicate-insulin-order
    May 04, 2012 - Duplicate Insulin Order Citation Text: Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. 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 Endn…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33771/psn-pdf
    August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety August 22, 2014 Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety Perspective The frontier of patient safety outside the hospital has y…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49822/psn-pdf
    March 01, 2018 - Isolated Clot, Real Error March 1, 2018 Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/isolated-clot-real-error Case Objectives Appreciate that errors are common in the management of venous thromboembolism disease. Describe patients with venous thromboembolism i…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33580/psn-pdf
    April 01, 2022 - Nursing and Patient Safety April 21, 2021 Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/nursing-and-patient-safety Updated in March 2021. Originally published in December 2011 by researchers at the University of California, San Francisco.  …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73642/psn-pdf
    August 25, 2021 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021 Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect- unexpected …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49651/psn-pdf
    May 01, 2012 - The Perils of Cross Coverage May 1, 2012 Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/perils-cross-coverage Case Objectives Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and care transitions. Describe ed…
  18. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
    January 01, 2022 - Spotlight Spotlight Delayed Diagnosis of Mesenteric Ischemia Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc o AHRQ WebM&M…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49527/psn-pdf
    December 01, 2006 - Right Patient, Wrong Sample December 1, 2006 Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample The Case A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On the morning of surgery, the patien…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33770/psn-pdf
    August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH August 1, 2014 In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of California, S…

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