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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865540/psn-pdf
    April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration April 11, 2024 Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration The Case An 82-year-old woman presented to the Emergency Department (ED) for …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837660/psn-pdf
    July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse Outcomes July 8, 2022 Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes The Cases Case 1: A 64-year-old man came in for a routine bron…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49388/psn-pdf
    February 01, 2003 - Unexplained Apnea Under Anesthesia February 1, 2003 Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia Case Objectives Clinical Objectives List the causes of prolonged apnea in the operating room Describe the steps in management …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49758/psn-pdf
    April 01, 2016 - Dropping to New Lows April 1, 2016 Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dropping-new-lows Case Objectives State how to manage diabetes medications when patients are admitted to the hospital Describe a guideline-recommended insulin regimen for a hospitaliz…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865412/psn-pdf
    March 27, 2024 - Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation March 27, 2024 Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatmen…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73336/psn-pdf
    May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers May 26, 2021 Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers The Case  …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49684/psn-pdf
    May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical Error May 1, 2013 Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error Case Objectives Appreciate that chemotherapy a…
  8. psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
    September 15, 2024 - Retained Surgical Items: Definition and Epidemiology. Citation Text: Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …
  9. psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
    March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. Citation Text: Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49852/psn-pdf
    February 01, 2019 - Triaging Interhospital Transfers February 1, 2019 Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/triaging-interhospital-transfers Case Objectives Recognize that transfer of patients between acute care hospitals is common. Realize that the interhospital transfer…
  11. psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
    April 12, 2023 - SPOTLIGHT CASE Triaging Interhospital Transfers Citation Text: Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX En…
  12. psnet.ahrq.gov/web-mm/transfusion-overload
    September 23, 2020 - SPOTLIGHT CASE Transfusion Overload Citation Text: Patel MS, Carson JL. Transfusion Overload. 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 En…
  13. psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
    March 15, 2023 - SPOTLIGHT CASE False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. Citation Text: Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866995/psn-pdf
    October 30, 2024 - A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis October 30, 2024 Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis Disclosur…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33669/psn-pdf
    May 01, 2018 - Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? May 1, 2018 Peterson JF. Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-system…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33647/psn-pdf
    March 01, 2007 - The Role of the Patient in Improving Patient Safety March 1, 2007 Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/role-patient-improving-patient-safety Perspective Patients have three roles in improving patient safety: helping to ensure thei…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33571/psn-pdf
    March 15, 2025 - Reporting Patient Safety Events March 15, 2025 Reporting Patient Safety Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/reporting-patient-safety-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in th…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33830/psn-pdf
    March 22, 2016 - Measuring and Responding to Deaths From Medical Errors March 22, 2016 Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors Annual Perspective 2016 The Prevalence of Deaths Due to Preventable Adve…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33800/psn-pdf
    January 01, 2015 - Computerized Provider Order Entry and Patient Safety January 1, 2015 Sarkar U, Shojania KG. Computerized Provider Order Entry and Patient Safety. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety Annual Perspective 2015 Computerized provider order entry…
  20. psnet.ahrq.gov/primer/culture-safety
    September 15, 2024 - Culture of Safety Citation Text: Culture of Safety. 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 XML Endnote tagged PubMedId RIS Dow…

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