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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33831/psn-pdf
    April 01, 2017 - In Conversation With… Mark Chassin, MD, MPP, MPH April 1, 2017 In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph Editor's note: Dr. Chassin is president and chief executive officer of The Joint Commission. He is also p…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49525/psn-pdf
    December 01, 2006 - Hidden Heparins: HIT Happens December 1, 2006 Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens Case Objectives Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication, thrombosis. Discuss the managem…
  3. psnet.ahrq.gov/print/pdf/node/854855
    January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Patient as a Team Member in Clinical Care Curated Library Foundations Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving Patient Safety. Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, F…
  4. psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx Spotlight Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/…
  5. psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
    May 01, 2005 - Delayed Breast Cancer Diagnosis: A False Sense of Security. Citation Text: Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cita…
  6. psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
    May 01, 2018 - SPOTLIGHT CASE Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency Citation Text: Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  7. psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
    January 31, 2024 - Annual Perspective Improving Diagnostic Safety and Quality Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD | April 26, 2023  View more articles from the same authors. Citation Text: Al-Khafaji J, Lee M, Mossburg S. Improving Di…
  8. psnet.ahrq.gov/web-mm/triple-handoff
    March 01, 2004 - SPOTLIGHT CASE Triple Handoff Citation Text: Vidyarthi A. Triple Handoff. 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 …
  9. psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
    November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn Citation Text: Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49793/psn-pdf
    May 01, 2017 - Hemolysis Holdup May 1, 2017 Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hemolysis-holdup The Case A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
  11. psnet.ahrq.gov/web-mm/mark-my-limb
    February 10, 2015 - Mark My Limb Citation Text: Jacott WE, O'Leary D. Mark My Limb. 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 …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49460/psn-pdf
    September 01, 2004 - Security Lapse September 1, 2004 Mason D. Security Lapse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/security-lapse The Case A medical student learned that the hospital's radiology image library was accessible throughout the university's computer system, meaning that patient x-rays could be viewed in d…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49541/psn-pdf
    August 21, 2007 - Mark My Tooth August 21, 2007 Smith RA. Mark My Tooth. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/mark-my-tooth The Case A 45-year-old healthy man was scheduled to have two teeth extracted for progressive dental caries. The patient underwent the extractions, awoke from the anesthesia, and then realized…
  14. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.356_slideshow.ppt
    September 01, 2015 - PowerPoint Presentation Spotlight Abdominal Pain in Early Pregnancy This presentation is based on the September 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Charlie C. Kilpatrick, MD, Associate Professor of Obstetrics and Gynecology, Baylor …
  15. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
    May 01, 2009 - Spotlight Case July 2008 Spotlight Case Delirium or Dementia? Source and Credits This presentation is based on the May 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James L. Rudolph, MD, SM Editor, AHRQ WebM&M: Robert Wachter, MD Sp…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33790/psn-pdf
    August 01, 2015 - New Insights on Safety and Health IT August 1, 2015 Hettinger ZA, Ratwani RM, Fairbanks RJ. New Insights on Safety and Health IT. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/new-insights-safety-and-health-it Perspective Despite the widespread adoption of electronic health records (EHRs) over the las…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33794/psn-pdf
    November 01, 2015 - In Conversation With… Lorri Zipperer, MA November 1, 2015 In Conversation With… Lorri Zipperer, MA. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma Editor's note: Lorri Zipperer, principal at Zipperer Project Management, was a founding staff member of the National Patient…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33627/psn-pdf
    February 01, 2006 - Removing Insult from Injury—Disclosing Adverse Events February 1, 2006 Wu AW. Removing Insult from Injury—Disclosing Adverse Events. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events Perspective You pull into a parking space, swing open the car door, and ar…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836878/psn-pdf
    April 27, 2022 - The Media’s Role in Patient Safety April 27, 2022 Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/medias-role-patient-safety Brief History of the Media Influencing Patient Safety Despite studies raising questions about avoidable ha…
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
    May 01, 2013 - Spotlight Case July 2008 Spotlight Case Right Regimen, Wrong Cancer: Patient Catches Medical Error * * Source and Credits This presentation is based on the May 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Joseph O. Jacobson, MD, MSc…

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