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2401. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33679/psn-pdf
      January 01, 2009 - Disclosure of Medical Error January 1, 2009 Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/disclosure-medical-error Perspective Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater discl…

2402. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49393/psn-pdf
      April 01, 2003 - Which End Is Which? April 1, 2003 Campbell AR. Which End Is Which? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/which-end-which The Case A 39-year-old woman with chronic peri-anal fistulas and infected anal sinuses underwent laparoscopic diverting colostomy to divert her fecal stream and allow the perine…

2403. Charcoal Lavage of the Lungs | PSNet
      psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
      January 01, 2016 - Charcoal Lavage of the Lungs Citation Text: Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

2404. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49656/psn-pdf
      June 01, 2012 - Comanagement: Who's in Charge? June 1, 2012 Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/comanagement-whos-charge The Case A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left hip fracture to the orthopedic surg…

2405. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49514/psn-pdf
      July 01, 2006 - One ACE Too Many July 1, 2006 Juurlink DN. One ACE Too Many. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/one-ace-too-many The Case A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure presented to the emergency department (ED) with chest pain. An acut…

2406. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49578/psn-pdf
      January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug Interaction January 1, 2009 Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction The Case A 40-year-old wo…

2407. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841468/psn-pdf
      December 14, 2022 - Don’t Bite Your Tongue. December 14, 2022 Singh NS. Don’t Bite Your Tongue. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/dont-bite-your-tongue The Case A 63-year-old woman with a past medical history of hypertension, osteoarthritis, migraine headaches, and daily smoking was admitted to a hospital for ant…

2408. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49845/psn-pdf
      October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages October 1, 2018 Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages The Case A 1-month-old preterm infant in the ne…

2409. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33844/psn-pdf
      October 01, 2017 - Health Care Worker Presenteeism: A Challenge for Patient Safety October 1, 2017 Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety Perspective Introduction Health care–as…

2410. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60548/psn-pdf
      May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020 In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food…

2411. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49390/psn-pdf
      February 01, 2003 - Flying Object Hits MRI February 1, 2003 Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/flying-object-hits-mri The Case A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an anesthesiologist, the child was receiving…

2412. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49590/psn-pdf
      January 01, 2010 - Is the Admission Drug Dose Too Low? August 1, 2009 Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low The Case A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to the hospit…

2413. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33829/psn-pdf
      March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety March 1, 2017 Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…

2414. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49697/psn-pdf
      December 01, 2013 - Check the Anesthesia Machine December 1, 2013 Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/check-anesthesia-machine The Case A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension, diabetes, sleep apnea…

2415. Selection Criteria and Honorarium Information | PSNet
      psnet.ahrq.gov/Webmm/submit-case-info
      August 10, 2025 - Selection Criteria and Honorarium Information How it works Health care professionals may submit de-identified cases that highlight medical errors or other patient safety/quality issues. Note that you can choose to submit cases either …

2416. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33601/psn-pdf
      December 15, 2024 - Electronic Health Records December 15, 2024 Electronic Health Records. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/electronic-health-records PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safet…

2417. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33681/psn-pdf
      March 01, 2009 - The Role of Health Literacy in Patient Safety March 1, 2009 Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety Perspective Clear health communication is increasingly recognized as essential for promoting …

2418. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33749/psn-pdf
      April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety? April 1, 2013 Fletcher KE, Reed DA. Are Residency Duty Hour Rules Improving Patient Safety? PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety Perspective Introduction The Accreditation Council f…

2419. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33761/psn-pdf
      February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness February 1, 2014 Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…

2420. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.287_slideshow.ppt
      December 01, 2012 - Spotlight Case July 2008 Spotlight Case The Lung Nodule That Refused To Grow * * Source and Credits This presentation is based on the December 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Alex A. Balekian, MD, MSHS, Keck School of Med…