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4881. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49709/psn-pdf
      May 01, 2014 - Raise the Bar May 1, 2014 Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/raise-bar The Case A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The patient was seen and evaluated by an anesthesiologist who was new to the cente…

4882. Not a Miscarriage | PSNet
      psnet.ahrq.gov/web-mm/not-miscarriage
      June 01, 2005 - Not a Miscarriage Citation Text: Learman LA. Not a Miscarriage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

4883. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841493/psn-pdf
      December 14, 2022 - Telehealth and Patient Safety. December 14, 2022 O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/telehealth-and-patient-safety Background In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications techno…

4884. The Magnetic Deflection | PSNet
      psnet.ahrq.gov/web-mm/magnetic-deflection
      November 18, 2016 - The Magnetic Deflection Citation Text: Kanal E. The Magnetic Deflection. 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 PubMe…

4885. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49808/psn-pdf
      October 01, 2017 - High-Risk Medications, High-Risk Transfers October 1, 2017 Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers The Case A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …

4886. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49622/psn-pdf
      March 01, 2011 - Dropping the Ball Despite an Integrated EMR March 1, 2011 Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr The Case A patient followed at a community-based clinic that is part of a large health care system with an in…

4887. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33633/psn-pdf
      May 01, 2006 - Patient Safety in the Physician Office Setting May 1, 2006 Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting Perspective Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …

4888. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49751/psn-pdf
      January 01, 2016 - New Patient Mistakenly Checked in as Another January 1, 2016 Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another The Case A 55-year-old man, presented to a primary care physician's office for an initial vis…

4889. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49453/psn-pdf
      July 01, 2004 - Bowel Prep July 1, 2004 Nelson D. Bowel Prep. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/bowel-prep The Case The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…

4890. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866846/psn-pdf
      September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 24, 2024 Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/zero…

4891. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49680/psn-pdf
      March 01, 2013 - Pathologic Mistake March 1, 2013 Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/pathologic-mistake The Case A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The discomfort worsened with eating. After losing 15 pounds …

4892. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49430/psn-pdf
      January 01, 2004 - Triage Time Bomb January 1, 2004 Washington DL. Triage Time Bomb. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/triage-time-bomb The Case A parent presented with a child to the emergency department (ED) triage area (located around the corner and down the hall from the actual ED). The child was febrile, an…

4893. Back to Basics | PSNet
      psnet.ahrq.gov/web-mm/back-basics
      July 13, 2010 - Back to Basics Citation Text: Hellman R. Back to Basics. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

4894. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33719/psn-pdf
      October 01, 2011 - The Context Is the Intervention October 1, 2011 Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/context-intervention Perspective Introduction What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this context.…

4895. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49782/psn-pdf
      January 01, 2017 - A Potent Medication Administered in a Not So Viable Route January 1, 2017 Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route The Case A 55-year-old man with history of nonischemic cardiomyop…

4896. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49655/psn-pdf
      June 01, 2012 - A Painful Dilemma June 1, 2012 Davison SN. A Painful Dilemma. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/painful-dilemma The Case A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with fever. She was taking propoxyphene or hydrocodone at home for pain. She h…

4897. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49785/psn-pdf
      February 01, 2017 - Refused Medication Error February 1, 2017 Foley M. Refused Medication Error. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/refused-medication-error The Case A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was alert to self and place only. The patient h…

4898. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33619/psn-pdf
      September 01, 2005 - In Conversation with…Carolyn Clancy, MD September 1, 2005 In Conversation with…Carolyn Clancy, MD. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md Editor's Note: Dr. Carolyn Clancy has been the Director of the Agency for Healthcare Research and Quality (AHRQ) since 200…

4899. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33694/psn-pdf
      April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010 In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a priva…

4900. Weekly Resource | PSNet
      psnet.ahrq.gov/periodic-issue/weekly-resource
      February 26, 2025 - March 12, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports,…