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  1. psnet.ahrq.gov/web-mm/watch-warfarin
    December 01, 2013 - SPOTLIGHT CASE Watch the Warfarin! Citation Text: Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…
  2. psnet.ahrq.gov/web-mm/eptifibatide-epilogue
    March 04, 2011 - Eptifibatide Epilogue Citation Text: Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
  3. psnet.ahrq.gov/web-mm/new-oral-anticoagulants
    July 01, 2011 - SPOTLIGHT CASE New Oral Anticoagulants Citation Text: Fang MC. New Oral Anticoagulants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  4. psnet.ahrq.gov/web-mm/other-side
    May 01, 2007 - SPOTLIGHT CASE The Other Side Citation Text: Vincent CA. The Other Side. 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 t…
  5. psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
    May 11, 2019 - SPOTLIGHT CASE The Consequences of Miscommunication Regarding a Possible Artifact Citation Text: Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33599/psn-pdf
    August 30, 2023 - Personal Health Literacy August 30, 2023 Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/personal-health-literacy Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…
  7. psnet.ahrq.gov/web-mm/code-status-confusion
    September 01, 2006 - SPOTLIGHT CASE Code Status Confusion Citation Text: Lo B, Tulsky JA. Code Status Confusion. 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 EndN…
  8. psnet.ahrq.gov/web-mm/failure-latch
    November 27, 2012 - Failure to Latch Citation Text: Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
  9. psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
    February 01, 2010 - The Role of Graduate Medical Education (GME) in Improving Patient Safety Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS | February 1, 2010  Also Read a Conversation View more articles from the same authors. Citation Text: Baron RB, Vidyarthi A. The Role of Gra…
  10. psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
    February 01, 2010 - In Conversation with…Thomas J. Nasca, MD February 1, 2010  Also Read an Essay Citation Text: In Conversation with…Thomas J. Nasca, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …
  11. 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…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73334/psn-pdf
    August 01, 2024 - An Inadvertent Bolus of Norepinephrine. May 26, 2021 Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…
  13. psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx Spotlight The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department Source and Credits • This presentation is based on the April 2023 AH…
  14. psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
    December 04, 2016 - SPOTLIGHT CASE An Inadvertent Bolus of Norepinephrine. Citation Text: Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation F…
  15. psnet.ahrq.gov/perspective/ems-patient-safety-field
    July 28, 2021 - EMS Patient Safety in the Field July 28, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…
  16. psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
    April 10, 2024 - Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes Citation Text: Bakerjian D. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49666/psn-pdf
    October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure October 1, 2012 Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure Case Objectives Identify risk f…
  18. psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
    February 26, 2025 - In Conversation With… Timothy B. McDonald, MD, JD April 1, 2019  Citation Text: In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy C…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866055/psn-pdf
    May 29, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle May 29, 2024 https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle Summary Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common catego…
  20. psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
    March 01, 2007 - The Role of the Patient in Improving Patient Safety Rosemary Gibson, MSc | March 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. Rockville…

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