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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. Add-on Case and the Missing Checklist | PSNet

    psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
    September 01, 2012 - Add-on Case and the Missing Checklist Citation Text: Catchpole K. Add-on Case and the Missing Checklist. 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 En…

  3. Suppl-Access Items Cg-Cahps-Child-Survey 2358-1A (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/cg/instructions/suppl-access_items_cg-cahps-child-survey_2358-1a.docx
    June 02, 2025 - CAHPS® Clinician & Group Survey 3.0 Supplemental Items: Access Population Version: Child Supplemental Access Items for the CAHPS® Clinician & Group Survey 3.0 Population Version: Child Language: English Users of the CAHPS® Clinician & Group Survey are free to incorporate supplemental items in order to meet the n…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49682/psn-pdf
    April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case April 1, 2013 Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49426/psn-pdf
    November 01, 2003 - Don't Push November 1, 2003 Meltzer HY. Don't Push. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dont-push The Case A 37-year-old HIV-positive woman was brought to the emergency room by her family because she had exhibited altered mentation for 3 days. The patient had been diagnosed with HIV infection 3 …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33721/psn-pdf
    November 01, 2011 - Lesson from the VA's Team Training Program November 1, 2011 Neily J, Mills PD, Paull DE, et al. Lesson from the VA's Team Training Program . PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/lesson-vas-team-training-program Perspective Introduction The Veterans Health Administration (VHA) National Center…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49833/psn-pdf
    June 01, 2018 - Perils in Diagnosing a Stroke June 1, 2018 Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke The Case A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was brought to the emergency depart…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49856/psn-pdf
    March 01, 2019 - Premature Extubation March 1, 2019 Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/premature-extubation The Case A 73-year-old woman with a history of carotid artery stenosis was admitted for an elective carotid endarterectomy. The procedure was initially thought to …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49794/psn-pdf
    May 01, 2017 - Communication Error in a Closed ICU May 1, 2017 Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/communication-error-closed-icu The Case A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney transplant), co…

  10. Anemia and Delayed Colon Cancer Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
    July 21, 2020 - SPOTLIGHT CASE Anemia and Delayed Colon Cancer Diagnosis Citation Text: Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …

  11. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures | PSNet

    psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
    November 16, 2022 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures Citation Text: Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  12. Right Regimen, Wrong Cancer: Patient Catches Medical Error | PSNet

    psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
    August 01, 2006 - SPOTLIGHT CASE Right Regimen, Wrong Cancer: Patient Catches Medical Error Citation Text: Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…

  13. Isolated Clot, Real Error | PSNet

    psnet.ahrq.gov/web-mm/isolated-clot-real-error
    December 01, 2013 - SPOTLIGHT CASE Isolated Clot, Real Error Citation Text: Parks A, Fang MC. Isolated Clot, Real Error. 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 X3…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49553/psn-pdf
    January 01, 2008 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures January 1, 2008 Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures The…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49670/psn-pdf
    November 01, 2012 - Missed Pneumonia November 1, 2012 Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/missed-pneumonia The Case A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic chest pain. Review of systems was negative for cough or dy…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49407/psn-pdf
    July 01, 2003 - Bleeding Risk July 1, 2003 Crowther MA. Bleeding Risk. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/bleeding-risk The Case A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial fibrillation, hypertension, coronary artery disease, and stroke. The surgi…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49769/psn-pdf
    September 01, 2016 - Complaints as Safety Surveillance September 1, 2016 Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance The Case A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain came on sudden…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49472/psn-pdf
    March 01, 2005 - Preventable Rash March 1, 2005 McLean C. Preventable Rash. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/preventable-rash The Case A 35-year-old man with HIV was being followed in an outpatient internal medicine clinic. At a routine visit, screening laboratories were checked. The clinic never contacted th…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49739/psn-pdf
    August 21, 2015 - Breathe Easy: Safe Tracheostomy Management August 21, 2015 Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management The Case A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33673/psn-pdf
    September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety September 1, 2008 Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety Perspective Medication safety in hospitals depends on the successful execu…
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