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  1. psnet.ahrq.gov/web-mm/perils-contrast-media
    March 01, 2007 - SPOTLIGHT CASE The Perils of Contrast Media Citation Text: Sadat U, Solomon R. The Perils of Contrast Media. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX En…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49482/psn-pdf
    May 01, 2005 - Pregnant With Danger May 1, 2005 Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pregnant-danger The Case A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of the night complaining of left leg pain. She also had so…
  3. psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
    February 26, 2025 - In Conversation with...Albert Wu, MD, MPH July 1, 2008  Citation Text: In Conversation with..Albert Wu, MD, MPH. PSNet [internet]. 2008.In Conversation with...Albert Wu, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49865/psn-pdf
    June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy June 1, 2019 Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy The Case A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49606/psn-pdf
    August 01, 2010 - Weighing In on Surgical Safety August 1, 2010 Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/weighing-surgical-safety Case Objectives Identify the comorbidites associated with obesity that place patients at higher risk for surgical complications. Un…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…
  7. psnet.ahrq.gov/web-mm/reaction-dye
    March 01, 2007 - Reaction to Dye Citation Text: Cohan R. Reaction to Dye. 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 …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33652/psn-pdf
    June 01, 2007 - Advancing Patient Safety Through State Reporting Systems June 1, 2007 Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems Perspective Seven years ago, the Institute of Medicine (I…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49760/psn-pdf
    May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49550/psn-pdf
    December 01, 2007 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? December 1, 2007 Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals The Case …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33643/psn-pdf
    December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA December 1, 2006 In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and Critic…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33754/psn-pdf
    September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD September 1, 2013 In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…
  13. psnet.ahrq.gov/web-mm/forgotten-line
    March 11, 2011 - The Forgotten Line Citation Text: Render ML. The Forgotten Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33839/psn-pdf
    August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS August 1, 2017 In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwester…
  15. psnet.ahrq.gov/toolkits
    March 01, 2025 - Toolkits Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols. Want to submit a Toolkit? Has your organization deve…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49712/psn-pdf
    June 01, 2014 - May I Have Another?—Medication Error June 1, 2014 Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error The Case A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a pharmacology-tra…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49857/psn-pdf
    March 01, 2019 - Duplicate Insulin Order March 1, 2019 Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/duplicate-insulin-order The Case A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency department (ED) for complaints of letharg…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49660/psn-pdf
    August 01, 2012 - No News May Not Be Good News August 1, 2012 Moore CR. No News May Not Be Good News. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news Case Objectives Describe the frequency with which ambulatory test results are not followed up by providers. Appreciate that inadequate follow-up of…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33696/psn-pdf
    June 01, 2010 - In Conversation with…Pat Croskerry, MD, PhD June 1, 2010 In Conversation with…Pat Croskerry, MD, PhD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd Editor's note: Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in Halifax, Nova…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33885/psn-pdf
    August 01, 2019 - In Conversation With… Susan Smith, MD August 1, 2019 In Conversation With… Susan Smith, MD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-smith-md Editor's note: Dr. Smith, a family medicine physician, is chief faculty practices officer for UCSF Health. Over the past 3–4 years, the …

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