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  1. psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
    May 19, 2021 - SPOTLIGHT CASE Postdischarge Follow-Up Phone Call Citation Text: Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Schol…
  2. psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
    December 02, 2020 - Updates in the Management of High-Risk Pulmonary Embolism Citation Text: Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Forma…
  3. psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
    October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case Citation Text: Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33618/psn-pdf
    September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety September 1, 2005 Wachter R. Playing Well with Others: "Translocational Research" in Patient Safety. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety Perspective Translation…
  5. psnet.ahrq.gov/web-mm/two-pills-same-drug
    May 27, 2011 - Two Pills, Same Drug Citation Text: Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
  6. psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
    July 01, 2004 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement Citation Text: Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy…
  7. psnet.ahrq.gov/web-mm/bleeding-risk
    November 01, 2003 - Bleeding Risk Citation Text: Crowther MA. Bleeding Risk. 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 tagged PubMedId RIS …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49425/psn-pdf
    November 01, 2003 - Misread Label November 1, 2003 Franklin BD. Misread Label. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/misread-label The Case An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine [Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49666/psn-pdf
    October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure October 1, 2012 Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure Case Objectives Identify risk f…
  10. psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
    May 01, 2008 - SPOTLIGHT CASE A Painful Medication Reconciliation Mishap Citation Text: Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google S…
  11. psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
    April 01, 2008 - Anticoagulation: Held Too Long Citation Text: Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49690/psn-pdf
    September 01, 2013 - The Pains of Chronic Opioid Usage September 1, 2013 Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage Case Objectives Describe the appropriate initial assessment of patients with chronic non-cancer pain. List the most comm…
  13. psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
    December 07, 2009 - SPOTLIGHT CASE No News May Not Be Good News Citation Text: Moore CR. No News May Not Be Good News. 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 X3 X…
  14. psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
    September 01, 2007 - SPOTLIGHT CASE Out of Sight, Out of Mind: Out-of-Office Test Result Management Citation Text: Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49651/psn-pdf
    May 01, 2012 - The Perils of Cross Coverage May 1, 2012 Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/perils-cross-coverage Case Objectives Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and care transitions. Describe ed…
  16. psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
    April 01, 2008 - SPOTLIGHT CASE A "Reflexive" Diagnosis in Primary Care Citation Text: Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34121/psn-pdf
    November 02, 2014 - Safety as You Go from Hospital to Home. November 2, 2014 National Patient Safety Foundation; NPSF https://psnet.ahrq.gov/issue/safety-you-go-hospital-home A review of steps for patients to make their transition home as safe as possible. https://psnet.ahrq.gov/issue/safety-you-go-hospital-home
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39190/psn-pdf
    December 16, 2009 - A long way to go. December 16, 2009 DerGurahian J. https://psnet.ahrq.gov/issue/long-way-go This article reports on accomplishments in patient safety since the To Err Is Human report was released. https://psnet.ahrq.gov/issue/long-way-go https://psnet.ahrq.gov/issue/err-human-building-safer-health-system
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49397/psn-pdf
    May 01, 2003 - The Dropped Lung May 1, 2003 Heffner JR. The Dropped Lung. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dropped-lung The Case A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73335/psn-pdf
    May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …

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