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  1. psnet.ahrq.gov/web-mm/patient-mix
    December 01, 2007 - Patient Mix-Up Citation Text: Shojania KG. Patient Mix-Up. 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 …
  2. psnet.ahrq.gov/web-mm/pca-overdose
    April 01, 2017 - PCA Overdose Citation Text: Doyle JD. PCA Overdose. 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 PubMedId RIS Dow…
  3. psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
    January 01, 2015 - If You Say So: Taking a Syringe at Face Value in the Operating Room Citation Text: Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cita…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849598/psn-pdf
    May 31, 2023 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023 https://psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve- management-sepsis Summary Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidiscip…
  5. psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
    September 01, 2006 - Anesthesia: A Weighty Issue Citation Text: Sinha AC. Anesthesia: A Weighty Issue. 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 tag…
  6. psnet.ahrq.gov/web-mm/magnetic-deflection
    November 18, 2016 - The Magnetic Deflection Citation Text: Kanal E. The Magnetic Deflection. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
  7. psnet.ahrq.gov/web-mm/hold-tpa
    July 29, 2020 - Hold the tPA Citation Text: Fagan SC. Hold the tPA. 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 PubMedId RIS Dow…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74242/psn-pdf
    January 07, 2022 - The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps January 7, 2022 Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps The Case A 52-year-old woman w…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49802/psn-pdf
    August 01, 2017 - Add-on Case and the Missing Checklist August 1, 2017 Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/add-case-and-missing-checklist The Case A 65-year-old woman was admitted for evaluation of abdominal pain and weight loss. Based on diagnostic data and ima…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49580/psn-pdf
    March 21, 2009 - Medication Reconciliation Victory After an Avoidable Error March 21, 2009 Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error The Case A 91-year-old woman, previously active and indepen…
  11. psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
    November 30, 2023 - A framework for assessing reasoning about controversial end-of-life clinical decisions. Citation Text: Fedyk M, Fairman N, Romano PS, et al. A framework for assessing reasoning about controversial end-of-life clinical decisions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49673/psn-pdf
    December 01, 2012 - A Real Heartache December 1, 2012 Polevoi SK. A Real Heartache. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/real-heartache The Case A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The pain began at rest, and it radiated to his back and left axilla. He had…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33751/psn-pdf
    January 01, 2014 - Strengthening the Business Case for Patient Safety May 1, 2013 Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety Perspective After more than a decade in the national spotlight, the problem of pati…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33611/psn-pdf
    July 01, 2005 - In Conversation with…Christopher P. Landrigan, MD April 1, 2005 In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md Editor's Note: In October 2004, in what immediately became a landmark paper in patient safety, Dr.…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49484/psn-pdf
    June 01, 2005 - Two Pills, Same Drug June 1, 2005 Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/two-pills-same-drug The Case A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past medical history included several AIDS-related complica…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49688/psn-pdf
    August 21, 2013 - Discharge Instructions in the PACU: Who Remembers? August 21, 2013 Engel KG. Discharge Instructions in the PACU: Who Remembers? PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers The Case A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49523/psn-pdf
    November 01, 2006 - Urinary Retention Dilemma November 1, 2006 Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma The Case Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy (BPH) and urinary hesitancy returned to th…
  18. 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 …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49517/psn-pdf
    August 01, 2006 - Miscalculated Risk August 1, 2006 Strassels SA. Miscalculated Risk. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/miscalculated-risk The Case A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2- week-old infant. He received Vicodin (hydrocodone and a…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33884/psn-pdf
    July 01, 2019 - Emerging Safety Issues in Artificial Intelligence July 1, 2019 Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence Perspective Background Since the beginning of digital health records, there has bee…

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