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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848125/psn-pdf
    April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023 McGrath S, Blike G, Gale B, et al. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50701/psn-pdf
    November 26, 2019 - In Conversation With... Heidi Wald, MD November 26, 2019 In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-heidi-wald-md Editor’s note: Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO. She has previously served as …
  3. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.317_slideshow.ppt
    March 01, 2014 - PowerPoint Presentation Spotlight Case Tough Call: Addressing Errors From Previous Providers 1 This presentation is based on the March 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: William Martinez, MD, MS, Assistant Professor of Medicine, …
  4. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
    July 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case July 2007 Resuscitation Errors: A Shocking Problem Source and Credits This presentation is based on the July 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available online Commentary by: Benjamin Abella, MD, MPhil, …
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
    July 01, 2012 - Spotlight Case July 2008 Spotlight Case Not-So-Therapeutic Tap * * Source and Credits This presentation is based on the July 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeffrey H. Barsuk, MD, MS; Northwestern University Feinberg Scho…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33625/psn-pdf
    January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions Remain January 1, 2006 Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain Perspective On August 2, 2005, Air France flig…
  7. 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…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73999/psn-pdf
    October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49492/psn-pdf
    November 01, 2005 - Reconciling Doses November 1, 2005 Federico F. Reconciling Doses. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/reconciling-doses Case Objectives List the steps involved in medication reconciliation. Describe the role of each of the stakeholders in medication reconciliation. Discuss how medication reconc…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72693/psn-pdf
    January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules January 29, 2021 Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules The Case A…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33786/psn-pdf
    May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational Uses May 1, 2015 Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses Perspective Reports of…
  12. psnet.ahrq.gov/web-mm/air-side-caution
    April 21, 2015 - Air on the Side of Caution Citation Text: Robertson JM, Pozner CN. Air on the Side of Caution. 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 XML EndNote 7 XM…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49422/psn-pdf
    November 01, 2003 - 40 of K November 1, 2003 Lesar TS. 40 of K. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/40-k The Case An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
  14. psnet.ahrq.gov/web-mm/amphotericin-toxicity
    April 01, 2014 - Amphotericin Toxicity Citation Text: Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49434/psn-pdf
    February 01, 2004 - Undiagnosed Vaginal Bleeding February 1, 2004 Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding The Case The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal bleeding. Over the past…
  16. psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
    December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable Citation Text: Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…
  17. 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…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49637/psn-pdf
    October 01, 2011 - The Dropped "No" October 1, 2011 Johnson AJ. The Dropped "No". PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropped-no The Case A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in his legs. Because the leg swelling was somewhat more pronounced in his…
  19. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
    January 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case January 2008 How Do Providers Recover from Errors? Source and Credits This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Colin P. West, MD, PhD, Mayo Clini…
  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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