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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49752/psn-pdf
    January 01, 2016 - Inadvertent Use of More Potent Acid Leads to Burn January 1, 2016 Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn The Case A 31-year-old woman came to the clinic for a routine well-woman evaluation. She…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49468/psn-pdf
    December 16, 2004 - Mark My Limb December 1, 2004 Jacott WE, O'Leary D. Mark My Limb. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/mark-my-limb The Case A patient went to the operating room (OR) for surgery on the lower leg. Per the Universal Protocol, the surgeon marked the proper leg prior to bringing the patient to the O…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49411/psn-pdf
    July 01, 2003 - Code Status Confusion July 1, 2003 Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/code-status-confusion Case Objectives Appreciate challenges of determining goals of care in hospitalized patients Understand patients’ common misconceptions about CPR List typical mist…
  4. 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…
  5. psnet.ahrq.gov/web-mm/reconciling-doses
    August 14, 2017 - SPOTLIGHT CASE Reconciling Doses Citation Text: Federico F. Reconciling Doses. 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 End…
  6. 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 …
  7. psnet.ahrq.gov/web-mm/caution-interrupted
    October 01, 2016 - Caution, Interrupted Citation Text: Wears RL. Caution, Interrupted. 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 R…
  8. psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
    October 01, 2018 - CVC Removal: A Procedure Like Any Other Citation Text: Feil M. CVC Removal: A Procedure Like Any Other. 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 End…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49675/psn-pdf
    February 01, 2013 - Delay in Treatment: Failure to Contact Patient Leads to Significant Complications February 1, 2013 Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complicat…
  10. psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
    June 01, 2015 - SPOTLIGHT CASE Empiric Steroids: the Good, the Bad, and the Ugly Citation Text: Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format:…
  11. psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
    March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? Citation Text: Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. C…
  12. psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
    January 22, 2020 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout Citation Text: Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
  13. psnet.ahrq.gov/web-mm/near-miss-bedside-medications
    February 01, 2006 - SPOTLIGHT CASE Near Miss with Bedside Medications Citation Text: Wu AW. Near Miss with Bedside Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX End…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49448/psn-pdf
    June 01, 2004 - Listen to the Family June 1, 2004 Campbell D. Listen to the Family. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/listen-family The Case Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The surgical resident examined the patient, an elderly woman with …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49390/psn-pdf
    February 01, 2003 - Flying Object Hits MRI February 1, 2003 Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/flying-object-hits-mri The Case A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an anesthesiologist, the child was receiving…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49697/psn-pdf
    December 01, 2013 - Check the Anesthesia Machine December 1, 2013 Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/check-anesthesia-machine The Case A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension, diabetes, sleep apnea…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49387/psn-pdf
    February 01, 2003 - Patient Mix-Up February 1, 2003 Shojania KG. Patient Mix-Up. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/patient-mix The Case Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general medical service at an academic medical center. Overnight, another man wit…
  18. psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - SPOTLIGHT CASE Intubation Mishap Citation Text: Weinger MB, Blike G. Intubation Mishap. 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 …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49731/psn-pdf
    April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33823/psn-pdf
    January 01, 2017 - Workplace Safety in Health Care January 1, 2017 Simon RW, Canacari EG. Workplace Safety in Health Care. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/workplace-safety-health-care Perspective The patient safety movement has highlighted the risks that patients face when receiving health care. But, impo…

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