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  1. psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
    February 01, 2014 - Wrong-Time Error With High-Alert Medication Citation Text: Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX…
  2. psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
    March 29, 2023 - Walking Out of a Hospital After Attempted Suicide Citation Text: Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Googl…
  3. psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
    November 25, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy Citation Text: Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49495/psn-pdf
    December 01, 2005 - Low on the Totem Pole December 1, 2005 Wachter R. Low on the Totem Pole. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/low-totem-pole Case Objectives Understand the concept of authority gradient List steps that can be taken to increase communication across an authority gradient Consider the current cultu…
  5. psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
    December 21, 2017 - High-Risk Medications, High-Risk Transfers Citation Text: Staggers N. High-Risk Medications, High-Risk Transfers. 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 …
  6. psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
    April 01, 2010 - SPOTLIGHT CASE Two Wrongs Don't Make a Right (Kidney) Citation Text: DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Schola…
  7. psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd
    April 26, 2023 - In Conversation With… Kathleen Sutcliffe, MN, PhD April 1, 2017  Citation Text: In Conversation With… Kathleen Sutcliffe, MN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy C…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33660/psn-pdf
    December 01, 2007 - In Conversation with...Eric Coleman, MD, MPH December 1, 2007 In Conversation with..Eric Coleman, MD, MPH. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph Editor's Note: Eric A. Coleman, MD, MPH, is Associate Professor of Medicine at the University of Colorado. Train…
  9. psnet.ahrq.gov/web-mm/routine-goes-awry
    September 23, 2020 - Routine Goes Awry Citation Text: Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49817/psn-pdf
    January 01, 2018 - Slow Down: Right Drug, Wrong Formulation January 1, 2018 Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation The Case A 65-year-old man presented to his primary care clinic for follow-up after a recent hospitaliz…
  11. psnet.ahrq.gov/web-mm/abnormal-volunteer-results
    July 18, 2016 - Abnormal Volunteer Results Citation Text: Fernandez C. Abnormal Volunteer Results. 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 Endnote ta…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33712/psn-pdf
    June 01, 2011 - In Conversation with… Edward Tenner, PhD June 1, 2011 In Conversation with… Edward Tenner, PhD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-edward-tenner-phd Editor's note: Edward Tenner is an independent writer, speaker, and consultant on technology and culture. He received his PhD fro…
  13. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
    January 01, 2019 - Spotlight Spotlight "Do You Want Everything Done?": Clarifying Code Status Source and Credits • This presentation is based on the December 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus M…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49504/psn-pdf
    March 01, 2006 - Liposuction Gone Awry March 1, 2006 Yates JA. Liposuction Gone Awry. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/liposuction-gone-awry The Case A 54-year-old man with HIV was referred to a plastic surgeon for cosmetic surgery. In the plastic surgeon’s office, he underwent neck and facial liposuction wit…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33642/psn-pdf
    November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006 In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you become interested…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49562/psn-pdf
    May 01, 2008 - The Inside of a Time Out May 1, 2008 Feldman DL. The Inside of a Time Out. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/inside-time-out The Case A 65-year-old man was scheduled for an elective endovascular repair of an abdominal aortic aneurysm. The patient had an allergy to "IV contrast dye" that was no…
  17. psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
    April 24, 2024 - Right Electrocardiogram, Wrong Patient Citation Text: Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote…
  18. psnet.ahrq.gov/web-mm/chest-tube-complications
    September 27, 2023 - Chest Tube Complications Citation Text: Santhosh L, Broaddus C. Chest Tube Complications. 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 EndNote 7 XML End…
  19. psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
    January 12, 2011 - Team Training: Classroom Training vs. High-Fidelity Simulation Stephen D. Pratt, MD and Benjamin P. Sachs, MB | March 1, 2006  View more articles from the same authors. Citation Text: Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulatio…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49457/psn-pdf
    September 01, 2004 - Doctor, Don't Treat Thyself September 1, 2004 Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself The Case A 50-year-old radiologist presented to the emergency department of the community hospital where he worked and reported increasing shortnes…

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