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  1. psnet.ahrq.gov/web-mm/or-peeping
    May 01, 2015 - OR Peeping Citation Text: Mackenzie CF. OR Peeping. 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 RIS Dow…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49401/psn-pdf
    May 01, 2003 - Suicidal Man With Gun May 1, 2003 Simon RI. Suicidal Man With Gun. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/suicidal-man-gun The Case The patient is a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe depression that had persisted for nearly 2 years. On initial inter…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50842/psn-pdf
    January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49731/psn-pdf
    April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…
  5. psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
    February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error Citation Text: Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49423/psn-pdf
    November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33832/psn-pdf
    April 01, 2017 - In Conversation With… Kathleen Sutcliffe, MN, PhD April 1, 2017 In Conversation With… Kathleen Sutcliffe, MN, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd Editor's note: Professor Sutcliffe is a Bloomberg Distinguished Professor of Business and Medicine at …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33625/psn-pdf
    January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions Remain January 1, 2006 Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain Perspective On August 2, 2005, Air France flig…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49715/psn-pdf
    August 21, 2014 - Liver Biopsy: Proceed With Caution August 21, 2014 Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution The Case A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast cancer, presented t…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49688/psn-pdf
    August 21, 2013 - Discharge Instructions in the PACU: Who Remembers? August 21, 2013 Engel KG. Discharge Instructions in the PACU: Who Remembers? PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers The Case A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33739/psn-pdf
    October 01, 2012 - The Physical Environment: An Often Unconsidered Patient Safety Tool October 1, 2012 Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool Perspective Now that…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33611/psn-pdf
    July 01, 2005 - In Conversation with…Christopher P. Landrigan, MD April 1, 2005 In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md Editor's Note: In October 2004, in what immediately became a landmark paper in patient safety, Dr.…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33786/psn-pdf
    May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational Uses May 1, 2015 Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses Perspective Reports of…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33650/psn-pdf
    May 01, 2007 - Patient Safety in the United Kingdom: Evolution and Progress May 1, 2007 Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evolution and Progress. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress Perspective The dangers of health care in B…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49823/psn-pdf
    March 01, 2018 - Shortcuts to Acetaminophen-induced Liver Failure March 1, 2018 Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure The Case An 18-year-old woman, 27 weeks pregnant, presented to the emergency dep…
  16. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.317_slideshow.ppt
    March 01, 2014 - PowerPoint Presentation Spotlight Case Tough Call: Addressing Errors From Previous Providers 1 This presentation is based on the March 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: William Martinez, MD, MS, Assistant Professor of Medicine, …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49815/psn-pdf
    December 01, 2017 - Over-the-Counter Oversight December 1, 2017 Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/over-counter-oversight The Case A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although portions of his skin we…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33884/psn-pdf
    July 01, 2019 - Emerging Safety Issues in Artificial Intelligence July 1, 2019 Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence Perspective Background Since the beginning of digital health records, there has bee…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49711/psn-pdf
    June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of Patient Wandering June 1, 2014 Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering Case Objectives Define patie…
  20. psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
    October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019  View more articles from the same authors. Citation Text: Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…

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