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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33753/psn-pdf
    August 22, 2013 - Update on Safety Culture August 22, 2013 Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/update-safety-culture Perspective Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians treat each other with r…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49667/psn-pdf
    October 01, 2012 - Looking for Meds in All the Wrong Places October 1, 2012 Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places The Case A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She went to t…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74022/psn-pdf
    March 01, 2021 - The Role of Community Pharmacists in Patient Safety October 25, 2021 Luchen GG, Hall KK, Hough KR. The Role of Community Pharmacists in Patient Safety . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety What is a community pharmacy? Community pharmacies are somet…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49647/psn-pdf
    February 01, 2012 - Amended Lab Results: Communication Slip February 1, 2012 Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip The Case A 25-year-old woman in her first pregnancy was seen at 33 weeks' gestation with new onset hypertension an…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49692/psn-pdf
    September 01, 2013 - A Picture Speaks 1000 Words September 1, 2013 Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words The Case A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection repair presented with chest p…

  6. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
    May 01, 2009 - Spotlight Case July 2008 Spotlight Case Delirium or Dementia? Source and Credits This presentation is based on the May 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James L. Rudolph, MD, SM Editor, AHRQ WebM&M: Robert Wachter, MD Sp…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49460/psn-pdf
    September 01, 2004 - Security Lapse September 1, 2004 Mason D. Security Lapse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/security-lapse The Case A medical student learned that the hospital's radiology image library was accessible throughout the university's computer system, meaning that patient x-rays could be viewed in d…

  8. Preventable Rash | PSNet

    psnet.ahrq.gov/web-mm/preventable-rash
    October 01, 2012 - Preventable Rash Citation Text: McLean C. Preventable Rash. 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 …

  9. 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. …

  10. One Bronchoscopy, Two Errors | PSNet

    psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
    December 09, 2020 - One Bronchoscopy, Two Errors Citation Text: Leiten E, Nielsen R. One Bronchoscopy, Two Errors. 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 XM…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60376/psn-pdf
    July 30, 2020 - COVID-19: Team and Human Factors to Improve Safety July 30, 2020 Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety Background The rapid transmission of COVID-19 has resulted in an international pandem…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49609/psn-pdf
    October 01, 2010 - Dangerous Dialysis October 1, 2010 Holley JL. Dangerous Dialysis . PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/dangerous-dialysis Case Objectives List common errors that occur in dialysis units. Describe steps that can be taken by dialysis units to prevent these common errors. Describe the role of the …

  13. 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…

  14. Missed Pneumonia | PSNet

    psnet.ahrq.gov/web-mm/missed-pneumonia
    June 01, 2005 - Missed Pneumonia Citation Text: Rohde JM, Flanders S. Missed Pneumonia. 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 XML EndNote 7 XML Endnote tagged PubMed…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33672/psn-pdf
    September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH September 1, 2008 In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph Editor's note: Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women's Hospital and Assi…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49664/psn-pdf
    January 01, 2013 - Empty Handoff September 1, 2012 Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/empty-handoff The Case A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a leg wound. The patient's medical history included chronic…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49582/psn-pdf
    April 01, 2009 - Breakage of a PICC Line April 1, 2009 Dimov V. Breakage of a PICC Line. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/breakage-picc-line Case Objectives Appreciate the incidence and consequences of PICC line breakage. Understand the risk factors for PICC line breakage. Understand the treatment options in…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49513/psn-pdf
    July 01, 2006 - Moving Pains July 1, 2006 Schell H, Wachter R. Moving Pains. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/moving-pains Case Objectives Appreciate the risk posed by intrahospital transport Identify key features of current transport practice and policies Propose interventions that might improve safety of …

  19. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
    May 01, 2017 - PowerPoint Presentation Spotlight Diagnostic Delay in the Emergency Department 1 Source and Credits This presentation is based on the May 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49594/psn-pdf
    December 01, 2009 - Standard Deviations December 1, 2009 Sabin JE. Standard Deviations. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/standard-deviations Case Objectives Understand the safety risks associated with patients being discharged against medical advice (AMA). Recognize safety risks associated with being part of a …
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