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  1. psnet.ahrq.gov/periodic-issue/periodic-issue-472
    February 26, 2025 - February 26, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, repor…
  2. psnet.ahrq.gov/primer/patient-safety-101
    January 16, 2025 - Patient Safety 101 Citation Text: Patient Safety 101. 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 D…
  3. psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
    February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room Citation Text: Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33845/psn-pdf
    November 01, 2017 - In Conversation With… Wanda Pratt, PhD November 1, 2017 In Conversation With… Wanda Pratt, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd Editor's note: Wanda Pratt is a Professor in the Information School with an adjunct appointment in the Division of Biomedical and …
  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/49592/psn-pdf
    October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49607/psn-pdf
    August 01, 2010 - Missed Patient Assignment: Is Anyone There? August 1, 2010 Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there The Case In one hospital, nurses' patient assignments were communicated by listing the…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50859/psn-pdf
    January 31, 2020 - In Conversation With... David Gruen, MD January 31, 2020 In Conversation With.. David Gruen, MD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-david-gruen-md Editor’s note: David R. Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson Health and is a thought leader and…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49673/psn-pdf
    December 01, 2012 - A Real Heartache December 1, 2012 Polevoi SK. A Real Heartache. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/real-heartache The Case A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The pain began at rest, and it radiated to his back and left axilla. He had…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33661/psn-pdf
    December 01, 2007 - Care Transitions December 1, 2007 Kripalani S. Care Transitions. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/care-transitions Perspective Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients pack their belongings and return home. Physicians scratch …
  11. 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…
  12. psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
    June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment Citation Text: Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
  13. psnet.ahrq.gov/web-mm/over-not-so-easy
    April 01, 2005 - Over Not So Easy Citation Text: Cucina R. Over Not So Easy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  14. psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
    February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error Citation Text: Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33673/psn-pdf
    September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety September 1, 2008 Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety Perspective Medication safety in hospitals depends on the successful execu…
  16. psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx Spotlight Premature Closure: Was it Just Syncope? Source and Credits • This presentation is based on the November 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit i…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49722/psn-pdf
    December 01, 2014 - Medical Devices in the "Wild" December 1, 2014 Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/medical-devices-wild The Case A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes, chronic pain, arthritis, and…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49815/psn-pdf
    December 01, 2017 - Over-the-Counter Oversight December 1, 2017 Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/over-counter-oversight The Case A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although portions of his skin we…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33832/psn-pdf
    April 01, 2017 - In Conversation With… Kathleen Sutcliffe, MN, PhD April 1, 2017 In Conversation With… Kathleen Sutcliffe, MN, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd Editor's note: Professor Sutcliffe is a Bloomberg Distinguished Professor of Business and Medicine at …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33699/psn-pdf
    August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers August 1, 2010 Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers Perspective Academic medical…

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