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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49522/psn-pdf
    November 01, 2006 - Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality November 1, 2006 Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50611/psn-pdf
    October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing October 30, 2019 Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing Case Objectives List the most common errors associated with computerized…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49651/psn-pdf
    May 01, 2012 - The Perils of Cross Coverage May 1, 2012 Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/perils-cross-coverage Case Objectives Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and care transitions. Describe ed…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49811/psn-pdf
    November 01, 2017 - Delayed Diagnosis of Endocrinologic Emergencies November 1, 2017 Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies The Cases Case #1: A 47-year-old man with a history of hyperthyroidism and h…
  5. psnet.ahrq.gov/web-mm/slippery-slide-life
    January 21, 2017 - Slippery Slide Into Life Citation Text: Halamek LP. Slippery Slide Into Life. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
  6. psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx Spotlight Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60865/psn-pdf
    August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA- BC-FACHE August 31, 2020 In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache Editor’s Note: Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is …
  8. 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…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49733/psn-pdf
    May 01, 2015 - Transitions in Adolescent Medicine May 1, 2015 Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transitions-adolescent-medicine The Case A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the emer…
  10. psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
    March 01, 2015 - SPOTLIGHT CASE Bad Writing, Wrong Medication Citation Text: Devine B. Bad Writing, Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  11. psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
    April 27, 2022 - Annual Perspective Patient Safety in the Ambulatory Care Setting August 5, 2022  View more articles from the same authors. Citation Text: Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. Rockville (MD): …
  12. psnet.ahrq.gov/web-mm/near-miss-bedside-medications
    February 01, 2006 - SPOTLIGHT CASE Near Miss with Bedside Medications Citation Text: Wu AW. Near Miss with Bedside Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX End…
  13. psnet.ahrq.gov/issue/errors-during-resuscitation-impact-perceived-authority-delivery-care
    April 03, 2019 - Study Errors during resuscitation: the impact of perceived authority on delivery of care. Citation Text: Delaloye NJ, Tobler K, OʼNeill T, et al. Errors during resuscitation: the impact of perceived authority on delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.000000000000035…
  14. psnet.ahrq.gov/issue/perceptions-impact-large-scale-collaborative-improvement-programme-experience-uk-safer
    February 01, 2011 - Study Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative. Citation Text: Benn J, Burnett S, Parand A, et al. Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK …
  15. psnet.ahrq.gov/issue/reducing-catheter-associated-bloodstream-infections-pediatric-intensive-care-unit-business
    November 23, 2016 - Study Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement. Citation Text: Nowak JE, Brilli RJ, Lake MR, et al. Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: Business …
  16. psnet.ahrq.gov/issue/expanding-role-antimicrobial-stewardship-programs-hospitals-united-states-lessons-learned
    March 04, 2015 - Study The expanding role of antimicrobial stewardship programs in hospitals in the United States: lessons learned from a multisite qualitative study. Citation Text: Kapadia SN, Abramson EL, Carter EJ, et al. The Expanding Role of Antimicrobial Stewardship Programs in Hospitals in the Uni…
  17. psnet.ahrq.gov/issue/impact-80-hour-resident-workweek-surgical-residents-and-attending-surgeons
    January 04, 2010 - Study The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Citation Text: Hutter MM, Kellogg KC, Ferguson CM, et al. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243(6):864-71; discussion 8…
  18. psnet.ahrq.gov/issue/performance-trigger-tool-identifying-adverse-events-oncology
    May 23, 2018 - Study Performance of a trigger tool for identifying adverse events in oncology. Citation Text: Lipitz-Snyderman A, Classen D, Pfister D, et al. Performance of a Trigger Tool for Identifying Adverse Events in Oncology. J Oncol Pract. 2017;13(3). doi:10.1200/jop.2016.016634. Copy Citatio…
  19. psnet.ahrq.gov/issue/errare-humanum-est-frequency-laterality-errors-radiology-reports
    September 13, 2023 - Study Errare humanum est: frequency of laterality errors in radiology reports. Citation Text: Sangwaiya MJ, Saini S, Blake MA, et al. Errare humanum est: frequency of laterality errors in radiology reports. AJR Am J Roentgenol. 2009;192(5):W239-44. doi:10.2214/AJR.08.1778. Copy Citatio…
  20. psnet.ahrq.gov/issue/universal-surveillance-methicillin-resistant-staphylococcus-aureus-3-affiliated-hospitals
    December 23, 2008 - Study Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Citation Text: Robicsek A, Beaumont JL, Paule SM, et al. Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals. Ann Intern Med. 2008;148(6)…

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