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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49586/psn-pdf
    May 01, 2009 - Vial Mistakes Involving Heparin May 1, 2009 Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin The Case A 65-year-old man was admitted to the hospital for an elective left carotid endarterectomy. During the procedure, the surgeon re…
  2. psnet.ahrq.gov/web-mm/situational-unawareness
    August 01, 2009 - Situational (Un)Awareness Citation Text: Abramson EL, Kaushal R. Situational (Un)Awareness. 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 E…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33838/psn-pdf
    July 01, 2017 - Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? July 1, 2017 Studdert DM. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know? PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-…
  4. psnet.ahrq.gov/web-mm/picture-speaks-1000-words
    July 16, 2015 - A Picture Speaks 1000 Words Citation Text: Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49575/psn-pdf
    November 01, 2008 - Sick and Pregnant November 1, 2008 El-Ibiary S. Sick and Pregnant. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/sick-and-pregnant The Case A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty breathing. The patient informed the staff that she was 17 weeks pre…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33701/psn-pdf
    October 01, 2010 - What Makes a Good Checklist October 1, 2010 McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/what-makes-good-checklist Perspective The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex tasks. Checklists have lo…
  7. psnet.ahrq.gov/web-mm/moved-too-soon
    November 01, 2006 - Moved Too Soon Citation Text: Lindenauer PK. Moved Too Soon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33880/psn-pdf
    May 01, 2019 - Safety in the Prehospital Emergency Medical Services Setting May 1, 2019 Patterson DP, Yealy DM. Safety in the Prehospital Emergency Medical Services Setting. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting Perspective Emergency medical services (E…
  9. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
    October 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case October 2007 Do Not Disturb! Source and Credits This presentation is based on the October 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available online Commentary by: F. Daniel Duffy, MD, University of Oklahoma, and…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865697/psn-pdf
    April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges April 24, 2024 Leary KB. In Conversation with..Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-a…
  11. psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx Spotlight When the Indications for Drug Administration Blur Source and Credits • This presentation is based on the June 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Julia Munsch,…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49465/psn-pdf
    December 22, 2021 - Electronic Err October 1, 2004 Tang PC. Electronic Err. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/electronic-err The Case A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest pain that that had not responded to three sublingual nitroglycerin tablets at…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73549/psn-pdf
    July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. July 28, 2021 Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty The Case A 61-year-old male patient weighing 57…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49726/psn-pdf
    March 01, 2015 - Two Wrongs Don't Make a Right (Kidney) March 1, 2015 DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney Case Objectives Review the current definition of wrong-site surgery. Describe the incidence of wrong-site surgery, and the…
  15. 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, …
  16. 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…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61080/psn-pdf
    October 28, 2020 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. October 28, 2020 DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33658/psn-pdf
    October 01, 2007 - In Conversation with...David Marx, JD October 1, 2007 In Conversation with..David Marx, JD. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd Editor's Note: An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49391/psn-pdf
    February 01, 2003 - When "Psychiatric" Symptoms Are Not February 1, 2003 Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not The Case A 70-year-old man without documented past psychiatric history was placed on an involuntary hold as a danger to oth…
  20. 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…

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