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  1. Wrong Turn through Colon: Misplaced PEG | PSNet

    psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
    May 01, 2017 - Wrong Turn through Colon: Misplaced PEG Citation Text: Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. 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…

  2. The Fluidity of Diagnostic "Wet Reads" | PSNet

    psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
    April 24, 2018 - The Fluidity of Diagnostic "Wet Reads" Citation Text: Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49871/psn-pdf
    August 10, 2019 - Renal Failure Due to Benign Prostatic Hyperplasia August 10, 2019 Barry MJ, Garnick MB. Renal Failure Due to Benign Prostatic Hyperplasia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia The Case A 65-year-old man was referred to urology for a 5-year history of …

  4. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet

    psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
    September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization Citation Text: Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…

  5. Pathologic Mistake | PSNet

    psnet.ahrq.gov/web-mm/pathologic-mistake
    February 15, 2010 - Pathologic Mistake Citation Text: Alaghehbandan R, Raab SS. Pathologic Mistake. 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 tagge…

  6. Patient Identification Errors: A Systems Challenge | PSNet

    psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
    February 23, 2011 - Patient Identification Errors: A Systems Challenge Citation Text: Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Googl…

  7. Over-the-Counter Oversight | PSNet

    psnet.ahrq.gov/web-mm/over-counter-oversight
    March 21, 2009 - Over-the-Counter Oversight Citation Text: Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. 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 End…

  8. Hard to Swallow | PSNet

    psnet.ahrq.gov/web-mm/hard-swallow
    April 26, 2023 - Hard to Swallow Citation Text: Driver J. Hard to Swallow. 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 …

  9. Liposuction Gone Awry | PSNet

    psnet.ahrq.gov/web-mm/liposuction-gone-awry
    July 01, 2003 - Liposuction Gone Awry Citation Text: Yates JA. Liposuction Gone Awry. 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 tagged PubMedId…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49612/psn-pdf
    November 01, 2010 - Treatment Challenges After Discharge November 1, 2010 Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge Case Objectives Understand types and frequencies of adverse events occurring between patient discharge from the hospital …

  11. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. | PSNet

    psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
    February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. Citation Text: Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49568/psn-pdf
    September 01, 2008 - Failure to Latch September 1, 2008 Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/failure-latch The Case The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to breastfeeding exclusively for 6 months. However, early br…

  13. Medical Devices in the "Wild" | PSNet

    psnet.ahrq.gov/web-mm/medical-devices-wild
    March 27, 2024 - Medical Devices in the "Wild" Citation Text: Gurses AP, Doyle PA. Medical Devices in the "Wild". 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 EndNote 7 …

  14. Liver Failure After Chemotherapy: Did We Forget Something? | PSNet

    psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
    May 01, 2019 - Liver Failure After Chemotherapy: Did We Forget Something? Citation Text: Lubel J. Liver Failure After Chemotherapy: Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: G…

  15. In Conversation With… Erik Hollnagel, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
    February 26, 2025 - In Conversation With… Erik Hollnagel, PhD June 1, 2019  Citation Text: In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Forma…

  16. Appendix V (continued) | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/long-term-care/resource/hcbs/report/apv1b.html
    June 01, 2010 - Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Appendix V (continued) Previous Page Next Page Table of Contents Environmental Scan of Measures for Medicaid Title XIX Home and Community-Based Services Executive Summary Introduction and Scan Methodology E…

  17. Haste Makes Care Unsafe | PSNet

    psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
    January 07, 2015 - Haste Makes Care Unsafe Citation Text: Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…

  18. Diagnostic Overshadowing Dangers | PSNet

    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…

  19. Environmental Safety in the OR | PSNet

    psnet.ahrq.gov/web-mm/environmental-safety-or
    May 19, 2015 - Environmental Safety in the OR Citation Text: Linkin DR, Lautenbach E. Environmental Safety in the OR . 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 En…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49419/psn-pdf
    October 01, 2003 - The Other Side October 1, 2003 Vincent CA. The Other Side. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/other-side Case Objectives List the factors contributing to wrong site surgery. Understand the key components of the Universal Protocol for eliminating wrong site, wrong procedure, wrong person surger…
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