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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842919/psn-pdf
    February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis. February 1, 2023 Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis The Cases Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
  2. psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
    June 15, 2024 - In Conversation With… Andrew Bindman, MD November 1, 2016  Citation Text: In Conversation With… Andrew Bindman, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation For…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49735/psn-pdf
    June 01, 2015 - Anchoring Bias With Critical Implications June 1, 2015 Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications Case Objectives Appreciate that diagnostic errors are common in primary and ambulatory care. Define premature clo…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49636/psn-pdf
    October 01, 2011 - Mobility Lost in the ICU October 1, 2011 Smith J. Mobility Lost in the ICU. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/mobility-lost-icu Case Objectives Describe the role of the physical therapist in the hospital and ICU. Compare the risks from immobility with the benefits gained from a program of ther…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841305/psn-pdf
    January 27, 2023 - In Conversation with... Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS December 14, 2022 In Conversation with.. Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps Editor’s Note: Ellen Deutsch, MD, MS, FACS, F…
  6. psnet.ahrq.gov/web-mm/failure-report
    July 01, 2008 - SPOTLIGHT CASE Failure to Report Citation Text: Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866578/psn-pdf
    August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy August 28, 2024 Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near- Miss Wrong Transfusion Event January 29, 2020 Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33855/psn-pdf
    April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM April 1, 2018 In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and Directo…
  10. psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx Spotlight Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837748/psn-pdf
    August 05, 2022 - Challenges of Diabetes Management and Medication Reconciliation August 5, 2022 Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation The Cases Case #1: A 53-year-old man …
  12. psnet.ahrq.gov/classics
    August 01, 2023 - Classics and Emerging Classics To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient sa…
  13. psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
    October 02, 2019 - SPOTLIGHT CASE One Toxic Drug Is Not Like Another Citation Text: Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTe…
  14. 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…
  15. psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
    October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis. Citation Text: Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bi…
  16. psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
    February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH April 1, 2014  Citation Text: In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citatio…
  17. psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
    March 31, 2021 - SPOTLIGHT CASE Delayed Diagnosis of Mesenteric Ischemia Citation Text: Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837808/psn-pdf
    August 05, 2024 - Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals. August 5, 2024 Washington, DC: Leapfrog Group; July 2024. https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis-recommended-practices-hospitals Diagnostic safety is beginning to be established as a systemic, rather than solely an ind…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836931/psn-pdf
    April 13, 2022 - Quality Special Issue. April 13, 2022 J Med Imaging Radiat Oncol. 2022;66(2):165-309. https://psnet.ahrq.gov/issue/quality-special-issue Improving patient safety related to radiology and radiation oncology is an ongoing priority. This special issue explores themes related to radiology and radiation oncology, inclu…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73097/psn-pdf
    March 31, 2011 - The Future of Nursing: Leading Change, Advancing Health. March 31, 2011 Institute of Medicine. Washington, DC: The National Academies Press: 2011. https://psnet.ahrq.gov/issue/future-nursing-leading-change-advancing-health The effective engagement of nursing is key to patient safety and care quality improvement. T…

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