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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865698/psn-pdf
    April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges April 24, 2024 Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges Introduction Nurses are essential to patient care, and having a…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33856/psn-pdf
    April 01, 2018 - Patient Safety During Hospital Discharge April 1, 2018 Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge Perspective Patients are admitted to the hospital in the United States 35 million times per year.(1)…
  3. psnet.ahrq.gov/web-mm/flying-object-hits-mri
    September 01, 2005 - Flying Object Hits MRI Citation Text: Gosbee JW, Gosbee LL. Flying Object Hits MRI. 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…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867652/psn-pdf
    February 26, 2025 - The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis Introduction Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863641/psn-pdf
    February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training February 28, 2024 Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…
  6. psnet.ahrq.gov/web-mm/moved-too-soon
    November 01, 2006 - Moved Too Soon Citation Text: Lindenauer PK. Moved Too Soon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  7. psnet.ahrq.gov/web-mm/listen-family
    April 15, 2015 - Listen to the Family Citation Text: Campbell D. Listen to the Family. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49614/psn-pdf
    November 01, 2010 - Reconciling Records November 1, 2010 Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/reconciling-records The Cases   Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local teaching hospital. When discharged, h…
  9. psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx Spotlight When the Indications for Drug Administration Blur Source and Credits • This presentation is based on the June 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Julia Munsch,…
  10. 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…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50843/psn-pdf
    January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia January 29, 2020 Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia The Case A 54-year-old man was brought t…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49686/psn-pdf
    May 01, 2013 - Don't Use That Port: Insert a PICC May 1, 2013 Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc The Case A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with fever and abdominal pain. A comp…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49479/psn-pdf
    April 01, 2005 - The Forgotten Med April 1, 2005 Cucina R. The Forgotten Med. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/forgotten-med The Case A 78-year-old woman with a history of chronic obstructive pulmonary disease (COPD) came to the hospital with increasing shortness of breath and chest pain. Although she had no …
  14. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
    January 01, 2015 - PowerPoint Presentation Spotlight Monitoring Fetal Health 1 This presentation is based on the January 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Mark W. Scerbo, PhD, Department of Psychology, Old Dominion University, and Alfred Z. Abuham…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33813/psn-pdf
    August 01, 2016 - Safety In Dentistry August 1, 2016 Ramoni R, Walji MF, Kalenderian E. Safety In Dentistry. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/safety-dentistry Perspective In a famous scene from the 1976 film, Marathon Man, Laurence Olivier, playing dentist Dr. Christian Szell tortures Babe Levy (played by…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49796/psn-pdf
    June 01, 2017 - Chest Tube Complications June 1, 2017 Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/chest-tube-complications The Case A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a spontaneous left pneumothorax (coll…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853772/psn-pdf
    September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable September 27, 2023 Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable The Case A fourteen-ye…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33634/psn-pdf
    May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia May 1, 2006 Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia Perspective Over the last decade, sur…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49761/psn-pdf
    May 01, 2016 - The Fluidity of Diagnostic "Wet Reads" May 1, 2016 Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads The Case A 64-year-old man with heavy tobacco use presented to the emergency department (ED) with chest pain. His electroc…
  20. psnet.ahrq.gov/web-mm/wrong-route-nutrients
    September 04, 2010 - Wrong Route for Nutrients Citation Text: Scott-Cawiezell JR. Wrong Route for Nutrients. 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 Endno…

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