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  1. psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
    June 01, 2014 - Mixup Beyond the Medication Label Citation Text: Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote …
  2. psnet.ahrq.gov/web-mm/overriding-considerations
    March 09, 2009 - Overriding Considerations Citation Text: Holtzman NA. Overriding Considerations. 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 tagg…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33838/psn-pdf
    July 01, 2017 - Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? July 1, 2017 Studdert DM. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33856/psn-pdf
    April 01, 2018 - Patient Safety During Hospital Discharge April 1, 2018 Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge Perspective Patients are admitted to the hospital in the United States 35 million times per year.(1)…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49853/psn-pdf
    February 01, 2019 - Adverse Event During Intrahospital Transport February 1, 2019 Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport The Case A 4-year-old boy underwent surgery under general anesthesia for correction o…
  6. psnet.ahrq.gov/web-mm/picture-speaks-1000-words
    July 16, 2015 - A Picture Speaks 1000 Words Citation Text: Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49709/psn-pdf
    May 01, 2014 - Raise the Bar May 1, 2014 Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/raise-bar The Case A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The patient was seen and evaluated by an anesthesiologist who was new to the cente…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33701/psn-pdf
    October 01, 2010 - What Makes a Good Checklist October 1, 2010 McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/what-makes-good-checklist Perspective The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex tasks. Checklists have lo…
  9. psnet.ahrq.gov/web-mm/listen-family
    April 15, 2015 - Listen to the Family Citation Text: Campbell D. Listen to the Family. 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…
  10. psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx Spotlight When the Indications for Drug Administration Blur Source and Credits • This presentation is based on the June 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Julia Munsch,…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49836/psn-pdf
    July 01, 2018 - Primary Workaround, Secondary Complication July 1, 2018 Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication The Case A young adult with a progressive neurological disorder presented to a hospital emerg…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49854/psn-pdf
    February 01, 2019 - Diagnostic Failure: The Growing Deficit February 1, 2019 Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit The Case A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61080/psn-pdf
    October 28, 2020 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. October 28, 2020 DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49686/psn-pdf
    May 01, 2013 - Don't Use That Port: Insert a PICC May 1, 2013 Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc The Case A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with fever and abdominal pain. A comp…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49447/psn-pdf
    June 01, 2004 - Dangerous Dapsone June 1, 2004 Bookwalter T. Dangerous Dapsone. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/dangerous-dapsone The Case A 78-year-old woman with newly diagnosed multiple myeloma on corticosteroids presented to the emergency department with dyspnea. Upon admission, she was found to be hypo…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49785/psn-pdf
    February 01, 2017 - Refused Medication Error February 1, 2017 Foley M. Refused Medication Error. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/refused-medication-error The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was alert to self and place only. The patient h…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33628/psn-pdf
    February 01, 2006 - In Conversation with…John Banja, PhD February 1, 2006 In Conversation with…John Banja, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd Editor's Note: John Banja, PhD, is Assistant Director for Health Sciences and Clinical Ethics and Associate Professor of Clinical Et…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49655/psn-pdf
    June 01, 2012 - A Painful Dilemma June 1, 2012 Davison SN. A Painful Dilemma. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/painful-dilemma The Case A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33705/psn-pdf
    January 01, 2011 - Risk Management and Patient Safety December 1, 2010 Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety Perspective In 1990, a Harvard-based research team reported the incidence of medical errors …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49704/psn-pdf
    March 01, 2014 - Late Anemia Following Rh Disease in a Newborn March 1, 2014 Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn The Case A full-term neonate was delivered uneventfully to an Rh-negative woman who had re…

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