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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49699/psn-pdf
    February 01, 2014 - Multifactorial Medication Mishap February 1, 2014 Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Id…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49608/psn-pdf
    August 01, 2010 - Emergent Triage Miss August 1, 2010 Travers D. Emergent Triage Miss. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/emergent-triage-miss The Case A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage nurse. The patient told the triage nurse that she had "3 days o…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854848/psn-pdf
    October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures October 31, 2023 Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures The Case A 32-year-old man presented to the hospital with…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33635/psn-pdf
    July 01, 2006 - In Conversation with...Allan Frankel, MD July 1, 2006 In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this kind of work. Dr. Allan …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49857/psn-pdf
    March 01, 2019 - Duplicate Insulin Order March 1, 2019 Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/duplicate-insulin-order The Case A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency department (ED) for complaints of letharg…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33710/psn-pdf
    May 01, 2011 - In Conversation with…Albert Wu, MD, MPH May 1, 2011 In Conversation with…Albert Wu, MD, MPH. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0 Editor's note: Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins School of Public Health. A…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33668/psn-pdf
    May 01, 2008 - In Conversation with…David W. Bates, MD, MSc May 1, 2008 In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and Quality …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49606/psn-pdf
    August 01, 2010 - Weighing In on Surgical Safety August 1, 2010 Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/weighing-surgical-safety Case Objectives Identify the comorbidites associated with obesity that place patients at higher risk for surgical complications. Un…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33774/psn-pdf
    December 01, 2014 - In Conversation With… Edward Kelley, PhD December 1, 2014 In Conversation With… Edward Kelley, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-edward-kelley-phd Editor's note: Edward Kelley, PhD, is Director of Service Delivery and Safety for the World Health Organization (WHO). He ha…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33822/psn-pdf
    January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA January 1, 2017 In Conversation With… Paul H. O'Neill, MPA. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa Editor's note: Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prio…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49798/psn-pdf
    July 01, 2017 - Pseudo-obstruction But a Real Perforation July 1, 2017 Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation Case Objectives Recognize acute colonic pseudo-obstruction and implement a medical management plan. Ide…

  12. Long-Term Care and the Response to COVID-19 | PSNet

    psnet.ahrq.gov/perspective/long-term-care-and-response-covid-19
    October 28, 2020 - KH : It's doing the root cause analysis and tackling the root causes before they actually lead to an

  13. In Conversation With... Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN | PSNet

    psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-popejoy-phd-rn-faan
    October 28, 2020 - KH : It's doing the root cause analysis and tackling the root causes before they actually lead to an

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73334/psn-pdf
    August 01, 2024 - administering multiple IV infusions concurrently is underappreciated and lack thereof can, in fact, lead

  15. The Role of Graduate Medical Education (GME) in Improving Patient Safety | PSNet

    psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
    February 01, 2010 - Second, residents are being trained to deliver a lifetime of clinical care and to lead complex health

  16. In Conversation with…Thomas J. Nasca, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
    February 01, 2010 - Second, residents are being trained to deliver a lifetime of clinical care and to lead complex health

  17. Assessing the Safety of Electronic Health Records: What Have We Learned? | PSNet

    psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
    September 01, 2017 - Assessing the Safety of Electronic Health Records: What Have We Learned? Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH | September 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Sittig DF, Singh H. Assessing the Safe…

  18. An Inadvertent Bolus of Norepinephrine. | PSNet

    psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
    December 04, 2016 - administering multiple IV infusions concurrently is underappreciated and lack thereof can, in fact, lead

  19. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
    January 01, 2023 - example, potassium supplements for a patient on furosemide is routine, however, this same drug may lead

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33785/psn-pdf
    May 01, 2015 - It was really eye opening for me as the lead of the study.
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