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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49854/psn-pdf
    February 01, 2019 - Diagnostic Failure: The Growing Deficit February 1, 2019 Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit The Case A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49427/psn-pdf
    January 01, 2004 - Inadvertent Castration January 1, 2004 Calland FJ. Inadvertent Castration. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/inadvertent-castration The Case An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently increased in size. The patient described persisten…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49661/psn-pdf
    August 01, 2012 - Residual Anesthesia: Tepid Burn August 1, 2012 Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn The Case A 42-year-old Filipino man presented to an outpatient surgery center for scheduled repair of an anal fistula. The pat…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33619/psn-pdf
    September 01, 2005 - In Conversation with…Carolyn Clancy, MD September 1, 2005 In Conversation with…Carolyn Clancy, MD. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md Editor's Note: Dr. Carolyn Clancy has been the Director of the Agency for Healthcare Research and Quality (AHRQ) since 200…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49680/psn-pdf
    March 01, 2013 - Pathologic Mistake March 1, 2013 Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pathologic-mistake The Case A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The discomfort worsened with eating. After losing 15 pounds …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33633/psn-pdf
    May 01, 2006 - Patient Safety in the Physician Office Setting May 1, 2006 Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting Perspective Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49808/psn-pdf
    October 01, 2017 - High-Risk Medications, High-Risk Transfers October 1, 2017 Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers The Case A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49616/psn-pdf
    December 01, 2010 - Milliliters vs. Milligrams December 1, 2010 Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams The Case   A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His evaluation showed acu…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49751/psn-pdf
    January 01, 2016 - New Patient Mistakenly Checked in as Another January 1, 2016 Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another The Case A 55-year-old man, presented to a primary care physician's office for an initial vis…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33630/psn-pdf
    March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity Simulation March 1, 2006 Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation Point–Counterpoint Editor's Note…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49756/psn-pdf
    April 01, 2016 - Lost in Sign Out and Documentation April 1, 2016 Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation The Case A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the emergency physician, …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49494/psn-pdf
    January 01, 2006 - One Dose, Fifty Pills November 1, 2005 Smith L. One Dose, Fifty Pills . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/one-dose-fifty-pills The Case A middle-aged man was admitted to the medical service of a teaching hospital with suspected vasculitis. When the initial diagnostic studies failed to provide …
  13. psnet.ahrq.gov/perspective/evolution-root-cause-analysis
    February 26, 2025 - If we think about it as a way of improving our culture of safety and increasing our ability to become
  14. psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - If we think about it as a way of improving our culture of safety and increasing our ability to become
  15. psnet.ahrq.gov/perspective/health-equity-and-maternal-health
    October 06, 2021 - considering approaches to address and mitigate root causes of disparities in maternal safety has become an increasing
  16. psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
    October 06, 2021 - considering approaches to address and mitigate root causes of disparities in maternal safety has become an increasing
  17. psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
    February 01, 2019 - experiences of care, population health, work life of clinicians, and reducing cost.( 5 ) There is an increasing
  18. psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
    July 01, 2012 - RW : When we look at the increasing availability of new kinds of decision support tools, every health
  19. psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
    January 01, 2008 - Also, at that meeting our corporate CEO proposed increasing the portion of each hospital CEO's total
  20. psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
    July 01, 2012 - RW : When we look at the increasing availability of new kinds of decision support tools, every health

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