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4901. 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…

4902. 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…

4903. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49584/psn-pdf
      April 01, 2009 - EMR Entry Error: Not So Benign April 1, 2009 Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign The Case A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint of shortness of breath. He was …

4904. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient | PSNet
      psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
      October 04, 2023 - From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient Citation Text: Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…

4905. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50392/psn-pdf
      September 01, 2019 - In Conversation With… Shantanu Agrawal, MD, MPhil September 1, 2019 In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil Editor's note: Dr. Agrawal is president and CEO of the National Quality Forum (NQF). He is the form…

4906. Treatment Challenges After Discharge | PSNet
      psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
      January 03, 2017 - SPOTLIGHT CASE Treatment Challenges After Discharge Citation Text: Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar Bib…

4907. Low on the Totem Pole | PSNet
      psnet.ahrq.gov/web-mm/low-totem-pole
      October 01, 2003 - SPOTLIGHT CASE Low on the Totem Pole Citation Text: Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

4908. The Unhappy Patient Leaves Against Medical Advice. | PSNet
      psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
      January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice. Citation Text: Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar …

4909. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49573/psn-pdf
      January 01, 2009 - Dangerous Shift November 1, 2008 Patterson ES. Dangerous Shift. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dangerous-shift Case Objectives Review the evidence base on erroneous actions related to shift changes. Understand the limits of standardizing handoffs in preventing errors at shift change. Expla…

4910. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49760/psn-pdf
      May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…

4911. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33652/psn-pdf
      June 01, 2007 - Advancing Patient Safety Through State Reporting Systems June 1, 2007 Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems Perspective Seven years ago, the Institute of Medicine (I…

4912. 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…

4913. Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet
      psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
      December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax Citation Text: Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …

4914. Slow Down: Right Drug, Wrong Formulation | PSNet
      psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
      October 13, 2018 - Slow Down: Right Drug, Wrong Formulation Citation Text: Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndN…

4915. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847934/psn-pdf
      April 26, 2023 - Patient Safety Indicators April 26, 2023 Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/patient-safety-indicators Background Over the past 25 years, policymakers and providers, payers, and purchasers of health care have increasingly focused attention on pati…

4916. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement | PSNet
      psnet.ahrq.gov/web-mm/navigating-complications-unintended-journey-guidewire-during-dialysis-catheter-placement
      February 23, 2022 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement Citation Text: Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

4917. Medication Administration Errors | PSNet
      psnet.ahrq.gov/primer/medication-administration-errors
      December 15, 2024 - Medication Administration Errors Citation Text: MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X…

4918. Personal Health Literacy | PSNet
      psnet.ahrq.gov/primer/personal-health-literacy
      October 31, 2023 - Personal Health Literacy Citation Text: Bakerjian D. Personal Health Literacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…

4919. Deprescribing as a Patient Safety Strategy | PSNet
      psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
      December 15, 2024 - Deprescribing as a Patient Safety Strategy Citation Text: Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX …

4920. Inappropriate Antibiotic Use | PSNet
      psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
      September 22, 2010 - Inappropriate Antibiotic Use Citation Text: Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. 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 …