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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. 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 …
  9. Psn-Pdf (pdf file)

    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)…
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. 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 …
  13. 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…
  14. Psn-Pdf (pdf file)

    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 …
  15. 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 …
  16. 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…
  17. 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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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