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psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - Delay in Initiating Antibiotics Results in Fatal Error
February 1, 2004
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
Case Objectives
Understand the importance of ongoing patient re-evaluati… 
                                     
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psnet.ahrq.gov/web-mm/urinary-retention-dilemma
March 01, 2013 - Urinary Retention Dilemma 
 
 
 
 
 Citation Text: 
 Joseph AC. Urinary Retention Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. 
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psnet.ahrq.gov/web-mm/allergy-holter
May 01, 2008 - Allergy to Holter 
 
 
 
 
 Citation Text: 
 Williams M. Allergy to Holter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. 
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psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - Mistaken Identity 
 
 
 
 
 Citation Text: 
 Hall LW. Mistaken Identity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. 
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psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - Risk Mitigation Using the Anesthesia Risk Alert Program:  Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner  
 
 
 
 
 
 
 
 
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psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - Critical Order Set Change and Critical Limb Ischemia 
 
 
 
 
 Citation Text: 
 Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. 
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple
Health System Vulnerabilities
May 26, 2021
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health
System Vulnerabilities. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult… 
                                     
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psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - Right Place, Right Drug, Wrong Strength 
 
 
 
 
 Citation Text: 
 Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. 
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psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications 
 
 
 
 
 Citation Text: 
 Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011… 
                                     
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psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
March 01, 2004 - Video to Improve Patient Safety: Clinical and Educational Uses 
 Yan Xiao, PhD; Colin F. Mackenzie, MB, ChB; and F. Jacob Seagull, PhD | May 1, 2015 
                       
 
 
 
 
 
 
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 Citation Text: 
 Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient S… 
                                     
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psnet.ahrq.gov/web-mm/painful-dilemma
September 01, 2013 - A Painful Dilemma 
 
 
 
 
 Citation Text: 
 Davison SN. A Painful Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. 
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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool 
 Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012 
                       
 
 
 
 
 
 
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 Citation Text: 
 Joseph A, Malone EB. The Physical Environment: An Often Unc… 
                                     
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psnet.ahrq.gov/node/49638/psn-pdf
January 01, 2012 - Communication Failure—Who's in Charge?
October 1, 2011
Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge
The Case
A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu… 
                                     
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psnet.ahrq.gov/node/861882/psn-pdf
January 31, 2024 - Patient Safety in Office-Based Care Settings
January 31, 2024
Ricciardi R, Lee M, Mossburg S. Patient Safety in Office-Based Care Settings. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
The Institute of Medicine’s 2000 publication To Err Is Human summarized res… 
                                     
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psnet.ahrq.gov/node/33697/psn-pdf
June 01, 2010 - What Do We Know About Emergency Department Safety?
June 1, 2010
Sklar DP, Crandall CS. What Do We Know About Emergency Department Safety? PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
Perspective
Emergency medicine has evolved from a location, with var… 
                                     
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - The Second Victim Phenomenon: A Harsh Reality of
Health Care Professions
May 1, 2011
Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [internet].
2011.
https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
Perspective
The Instit… 
                                     
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - Electronic Err 
 
 
 
 
 Citation Text: 
 Tang PC. Electronic Err. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. 
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psnet.ahrq.gov/node/60609/psn-pdf
June 24, 2020 - When the Indications for Drug Administration Blur
June 24, 2020
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accre… 
                                     
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - A Mistaken Dose of Naloxone?
December 18, 2019
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
The Case
A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up
appointment. He h… 
                                     
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psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
January 12, 2011 - Team Training: Classroom Training vs. High-Fidelity Simulation 
 Stephen D. Pratt, MD and Benjamin P. Sachs, MB | March 1, 2006 
                       
 
 
 
 
 
 
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 Citation Text: 
 Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulatio…