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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837748/psn-pdf
    August 05, 2022 - readmitted 10 days later with another episode of severe hypoglycemia and a humeral fracture caused by a fall
  2. psnet.ahrq.gov/web-mm/see-patient-first
    September 27, 2023 - 2) activation of a code or rapid response, 3) a significant change in clinical status, 4) a patient fall
  3. psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
    October 01, 2004 - reporting hospital-specific mortality following coronary bypass surgery, mortality rates were observed to fall
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867357/psn-pdf
    December 18, 2024 - tube (ETT) placement was confirmed by auscultation of breath sounds and observation of chest rise and fall
  5. psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
    January 01, 2024 - Dangerous mechanism (i.e., pedestrian struck by motor vehicle, occupant ejected from motor vehicle, or fall
  6. psnet.ahrq.gov/web-mm/crossed-coverage
    September 01, 2015 - Crossed Coverage Citation Text: Kayser SR. Crossed Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  7. psnet.ahrq.gov/web-mm/poor-prognosis
    March 15, 2016 - SPOTLIGHT CASE Poor Prognosis Citation Text: Lamont EB. Poor Prognosis. 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 ta…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865374/psn-pdf
    March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and Challenges March 27, 2024 Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges Introducti…
  9. psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
    February 12, 2020 - Diagnostic Overshadowing Dangers Citation Text: Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49630/psn-pdf
    July 01, 2011 - Watch the Warfarin! July 1, 2011 Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/watch-warfarin Case Objectives Understand best practices for safe discharge of patients on warfarin. Describe recent advances in anticoagulation monitoring for ambulatory patients. Discu…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50769/psn-pdf
    February 15, 2017 - Cultural Competence and Patient Safety December 27, 2019 Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety Background   Culture can be defined as the “personal identification, language, thoughts, co…
  12. psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
    October 19, 2022 - CYP450 Drugs: Expect the Unexpected Citation Text: Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…
  13. psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
    November 08, 2013 - Diffusion of Responsibility Leads to Danger Citation Text: Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33788/psn-pdf
    June 01, 2015 - In Conversation With… Christine Cassel, MD June 1, 2015 In Conversation With… Christine Cassel, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-christine-cassel-md Editor's note: Christine Cassel, MD, is President and CEO of the National Quality Forum (NQF). Dr. Cassel, one of the foun…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49594/psn-pdf
    December 01, 2009 - Standard Deviations December 1, 2009 Sabin JE. Standard Deviations. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/standard-deviations Case Objectives Understand the safety risks associated with patients being discharged against medical advice (AMA). Recognize safety risks associated with being part of a …
  16. psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
    December 01, 2017 - Unexpected Drawbacks of Electronic Order Sets Citation Text: McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49806/psn-pdf
    September 01, 2017 - Failed Interpretation of Screening Tool: Delayed Treatment September 1, 2017 Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment The Case An 88-year-old man present…
  18. psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
    August 21, 2007 - SPOTLIGHT CASE Wandering Off the Floors: Safety and Security Risks of Patient Wandering Citation Text: Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…
  19. psnet.ahrq.gov/clinical-areas
    March 24, 2025 - Clinical Areas Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources. Latest by Clinical Areas In Conversation with Edwin Boudreaux about S…
  20. psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
    March 21, 2009 - A Mistaken Dose of Naloxone  Citation Text: Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . 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 …

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