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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33739/psn-pdf
    October 01, 2012 - The Physical Environment: An Often Unconsidered Patient Safety Tool October 1, 2012 Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool Perspective Now that…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49731/psn-pdf
    April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…

  3. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
    May 01, 2015 - PowerPoint Presentation Spotlight Errors in Sepsis Management This presentation is based on the May 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF) Editor, AHRQ WebM&M: Rober…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49592/psn-pdf
    October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49707/psn-pdf
    April 01, 2014 - CYP450 Drugs: Expect the Unexpected April 1, 2014 Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected The Case A 42-year-old man with acquired immunodeficiency syndrome (AIDS) (CD4 count 198), hip dystocia, and generalized anxiety …

  6. Too Many Cooks Spotlight Pdf (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
    January 01, 2020 - Spotlight Too Many Cooks in the Kitchen Source and Credits • This presentation is based on the August 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Richard P. Dutton, MD, MBA o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…

  7. Critical Opportunity Lost | PSNet

    psnet.ahrq.gov/web-mm/critical-opportunity-lost
    February 17, 2017 - Critical Opportunity Lost Citation Text: Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49397/psn-pdf
    May 01, 2003 - The Dropped Lung May 1, 2003 Heffner JR. The Dropped Lung. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dropped-lung The Case A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49538/psn-pdf
    June 01, 2007 - Abnormal Volunteer Results June 1, 2007 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results The Case A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent magnetic resonance imaging (MRI) of her abdo…

  10. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.85_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49722/psn-pdf
    December 01, 2014 - Medical Devices in the "Wild" December 1, 2014 Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/medical-devices-wild The Case A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes, chronic pain, arthritis, and…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33881/psn-pdf
    August 01, 2019 - In Conversation With… Erik Hollnagel, PhD June 1, 2019 In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33775/psn-pdf
    December 01, 2014 - African Partnerships for Patient Safety: Lessons Learned December 1, 2014 Syed SS. African Partnerships for Patient Safety: Lessons Learned. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned Perspective In the last 6 years I have had the privilege of sha…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49837/psn-pdf
    August 01, 2018 - Abdominal Aortic Aneurysm Screening August 1, 2018 Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening Case Objectives Describe risk factors associated with abdominal aortic aneurysm. Identify patient populations meeting criteria fo…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49641/psn-pdf
    November 01, 2011 - Liver Failure After Chemotherapy: Did We Forget Something? November 1, 2011 Lubel J. Liver Failure After Chemotherapy: Did We Forget Something? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something The Case A 51-year-old Cantonese-speaking female with a his…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33786/psn-pdf
    May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational Uses May 1, 2015 Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses Perspective Reports of…

  17. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49725/psn-pdf
    January 01, 2015 - Haste Makes Care Unsafe January 1, 2015 Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/haste-makes-care-unsafe The Case An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined elective coronary artery bypass graft (CABG…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49459/psn-pdf
    September 01, 2004 - Caution, Interrupted September 1, 2004 Wears RL. Caution, Interrupted. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/caution-interrupted The Case A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and neutropenia presented to the emergency department (ED) with …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49401/psn-pdf
    May 01, 2003 - Suicidal Man With Gun May 1, 2003 Simon RI. Suicidal Man With Gun. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/suicidal-man-gun The Case The patient is a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe depression that had persisted for nearly 2 years. On initial inter…
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