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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near- Miss Wrong Transfusion Event January 29, 2020 Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838900/psn-pdf
    October 27, 2022 - Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. October 27, 2022 Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/fecal-contamination-…

  3. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
    January 01, 2022 - Spotlight Spotlight Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong Source and Credits • This presentation is based on the October 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60329/psn-pdf
    May 14, 2020 - In Conversation With... Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD May 14, 2020 In Conversation With.. Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md Editor’s note: Joel Willis, DO, PA, M…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49392/psn-pdf
    April 01, 2003 - Another Fall April 1, 2003 Bogardus SG. Another Fall. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/another-fall Case Objectives List risk factors for falls in hospitalized patients Understand appropriate use of restraints Identify system issues contributing to falls in hospitalized patients Case & Comm…

  6. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…

  7. Delirium or Dementia? | PSNet

    psnet.ahrq.gov/web-mm/delirium-or-dementia
    September 27, 2023 - SPOTLIGHT CASE Delirium or Dementia? Citation Text: Rudolph JL. Delirium or Dementia?. 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…

  8. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care | PSNet

    psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
    September 09, 2013 - SPOTLIGHT CASE Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care Citation Text: Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50698/psn-pdf
    November 27, 2019 - Missed Opportunities for Suicide Risk Assessment November 27, 2019 Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…

  10. Suicidal Ideation in the Family Medicine Clinic | PSNet

    psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
    October 01, 2007 - SPOTLIGHT CASE Suicidal Ideation in the Family Medicine Clinic Citation Text: Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …

  11. In Conversation With… Kaveh Shojania, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
    February 26, 2025 - In Conversation With… Kaveh Shojania, MD November 1, 2015  Citation Text: In Conversation With… Kaveh Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…

  12. Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle | PSNet

    psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
    July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 29, 2024 View more articles from the same authors. Inno…

  13. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure | PSNet

    psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
    March 01, 2005 - SPOTLIGHT CASE CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure Citation Text: Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…

  14. A Sweet Case of Hidden Hydrogen Ions | PSNet

    psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
    November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions Citation Text: Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. 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 X3 X…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33776/psn-pdf
    January 01, 2015 - In Conversation With… Mark Graban, MS, MBA January 1, 2015 In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba Editor's note: Mark Graban, MS, MBA, is an internationally recognized expert in Lean Healthcare, which has become one of…

  16. In Conversation With… Tejal K. Gandhi, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
    February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH April 1, 2014  Citation Text: In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citatio…

  17. Time of Death? | PSNet

    psnet.ahrq.gov/web-mm/time-death
    January 03, 2017 - Time of Death? Citation Text: Taekman JM, Wright MC. Time of Death?. 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 XML Endnote tagged PubMedId …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33855/psn-pdf
    April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM April 1, 2018 In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and Directo…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49534/psn-pdf
    May 01, 2007 - Antiseizure Medication Disorder May 1, 2007 Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder Case Objectives Appreciate the challenges of safe use of antiepileptic medications. Identify phenytoin toxicity. Understand the pharmaco…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33831/psn-pdf
    April 01, 2017 - In Conversation With… Mark Chassin, MD, MPP, MPH April 1, 2017 In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph Editor's note: Dr. Chassin is president and chief executive officer of The Joint Commission. He is also p…
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