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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49510/psn-pdf
    May 01, 2006 - Cups of Error May 1, 2006 Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/cups-error The Case An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered from dementia, he remained alert and oriented with only mild short-term memory…
  2. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.128_slideshow.ppt
    July 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case July 2006 Moving Pains Source and Credits This presentation is based on the June/July 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Hildy Schell, RN, MS, CCRN, CCNS, and…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49505/psn-pdf
    March 01, 2006 - Collegiality vs. Competence March 1, 2006 Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/collegiality-vs-competence The Case A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective repair of a 10-cm abdominal aortic aneurys…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49439/psn-pdf
    March 01, 2004 - Lethal Cap March 1, 2004 Schillinger D. Lethal Cap. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-cap The Case A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49393/psn-pdf
    April 01, 2003 - Which End Is Which? April 1, 2003 Campbell AR. Which End Is Which? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/which-end-which The Case A 39-year-old woman with chronic peri-anal fistulas and infected anal sinuses underwent laparoscopic diverting colostomy to divert her fecal stream and allow the perine…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33735/psn-pdf
    August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It August 1, 2012 Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it Perspective At any point in time, …
  7. psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
    January 01, 2020 - Spotlight Spotlight Suicidal Ideation in the Family Medicine Clinic 1 Source and Credits This presentation is based on the December 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Christine Moutier, MD, Chief Medical Officer, American …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49514/psn-pdf
    July 01, 2006 - One ACE Too Many July 1, 2006 Juurlink DN. One ACE Too Many. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/one-ace-too-many The Case A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure presented to the emergency department (ED) with chest pain. An acut…
  9. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
    December 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case December 2007 Elopement Source and Credits This presentation is based on the December 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Debra Gerardi, RN, MPH, JD Creighton University School of Law Ed…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49697/psn-pdf
    December 01, 2013 - Check the Anesthesia Machine December 1, 2013 Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/check-anesthesia-machine The Case A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension, diabetes, sleep apnea…
  11. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
    December 01, 2010 - Spotlight Case July 2008 Spotlight Case The Forgotten Turn * * Source and Credits This presentation is based on the December 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Susan Barbour, RN, FNP, University of California San Francisco …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33749/psn-pdf
    April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety? April 1, 2013 Fletcher KE, Reed DA. Are Residency Duty Hour Rules Improving Patient Safety? PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety Perspective Introduction The Accreditation Council f…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49619/psn-pdf
    February 01, 2011 - Paradoxical Pulse February 1, 2011 Roy CL. Paradoxical Pulse. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/paradoxical-pulse The Case An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful pacemaker placement as an outpatient. The patient was restarted on …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33868/psn-pdf
    October 01, 2018 - Safety in the Retail Pharmacy October 1, 2018 Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/safety-retail-pharmacy Perspective There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each year.(1) Many patients interact w…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33747/psn-pdf
    March 01, 2013 - The Literature on Health Care Simulation Education: What Does It Show? March 1, 2013 Cook DA. The Literature on Health Care Simulation Education: What Does It Show? PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show Perspective The education o…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33812/psn-pdf
    August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD August 1, 2016 In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd Editor's note: Dr. Perea-Pérez is Director de la Escuela de Medicina Legal y For…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49842/psn-pdf
    September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…
  18. psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
    February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Essay View more articles from the same authors. Citation Text: Savitz LA, S…
  19. psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
    March 01, 2011 - What Have We Learned About Safe Inpatient Handovers? Sunil Kripalani, MD, MSc | March 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Kripalani S. What Have We Learned About Safe Inpatient Handovers?. PSNet [internet]. …
  20. psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
    February 26, 2025 - Learning Health Systems for Patient Safety Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Savitz LA, Sousane Z, Mossburg SE. Learning …

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