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psnet.ahrq.gov/node/49404/psn-pdf
June 01, 2003 - Not a Miscarriage
June 1, 2003
Learman LA. Not a Miscarriage. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/not-miscarriage
The Case
A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented
at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…
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psnet.ahrq.gov/node/49548/psn-pdf
October 01, 2007 - Toxic Tachycardia
October 1, 2007
Wartofsky L. Toxic Tachycardia. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/toxic-tachycardia
The Case
A 66-year-old woman with a past medical history of hypertension and breast cancer was admitted with
abdominal pain. She complained of 3 weeks of progressive severe rig…
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psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration
errors in the operating room.
March 25, 2020
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…
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psnet.ahrq.gov/node/49867/psn-pdf
July 02, 2019 - Diuretics and Electrolyte Abnormalities
July 2, 2019
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
Case Objectives
Recognize that thiazide diuretics can lead to serious adverse events.
State how commonly used t…
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Is the Admission Drug Dose Too Low?
August 1, 2009
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
The Case
A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to
the hospit…
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psnet.ahrq.gov/node/49634/psn-pdf
September 01, 2011 - Situational (Un)Awareness
September 1, 2011
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/situational-unawareness
The Case
A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver
function tests, including a bi…
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psnet.ahrq.gov/node/49469/psn-pdf
December 01, 2004 - Overriding Considerations
December 1, 2004
Holtzman NA. Overriding Considerations. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/overriding-considerations
The Case
Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic
testing for a variety of condition…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.230_slideshow.ppt
December 01, 2010 - Spotlight Case July 2008
Spotlight Case
The Forgotten Turn
*
*
Source and Credits
This presentation is based on the December 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Susan Barbour, RN, FNP, University of California San Francisco …
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - Suicide Risk in the Hospital
May 1, 2018
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/suicide-risk-hospital
The Case
A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder
presented to the emergency department (ED)…
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psnet.ahrq.gov/node/33761/psn-pdf
February 01, 2014 - Interruptions and Distractions in Health Care: Improved
Safety With Mindfulness
February 1, 2014
Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet
[internet]. 2014.
https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…
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psnet.ahrq.gov/node/72737/psn-pdf
February 09, 2021 - Geisinger’s Outpatient Addiction Medicine Specialty
Program Uses Data-Driven Decision Making and MAT to
Reduce Mortality Rates
February 9, 2021
https://psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-
driven-decision
Summary
The team at Geisinger sought to develop a…
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psnet.ahrq.gov/primer/missed-nursing-care
September 15, 2024 - Missed Nursing Care
Citation Text:
Missed Nursing Care. 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
…
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psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
April 01, 2008 - Annual Perspective
Measuring and Responding to Deaths From Medical Errors
Sumant Ranji, MD | March 22, 2016
View more articles from the same authors.
Citation Text:
Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. Rockville…
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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
-
psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
…
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psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - Measurement of Patient Safety
Citation Text:
Measurement of Patient Safety. 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 Pu…
-
psnet.ahrq.gov/perspective/accountability-patient-safety
January 01, 2018 - Annual Perspective
Accountability in Patient Safety
Christopher Moriates, MD, and Robert M. Wachter, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. Rock…
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psnet.ahrq.gov/node/33602/psn-pdf
March 15, 2025 - Individual Clinician Performance Issues
March 15, 2025
Individual Clinician Performance Issues. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/individual-clinician-performance-issues
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current res…
-
psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - Fumbled Handoff
March 1, 2004
Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/fumbled-handoff
The Case
A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and
chronic renal insufficiency was admitted for an elective sigmoid resect…
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psnet.ahrq.gov/node/49439/psn-pdf
March 01, 2004 - Lethal Cap
March 1, 2004
Schillinger D. Lethal Cap. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-cap
The Case
A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to
have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…