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  1. Preventable Transfer to the Hospital | PSNet

    psnet.ahrq.gov/web-mm/preventable-transfer-hospital
    March 31, 2022 - Preventable Transfer to the Hospital Citation Text: Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar Bi…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33717/psn-pdf
    September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please September 1, 2011 Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please …

  3. The Wrongful Resuscitation | PSNet

    psnet.ahrq.gov/web-mm/wrongful-resuscitation
    October 12, 2012 - The Wrongful Resuscitation Citation Text: Teno JM. The Wrongful Resuscitation. 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 tagged…

  4. Haste Makes Care Unsafe | PSNet

    psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
    January 07, 2015 - Haste Makes Care Unsafe Citation Text: Eichhorn JH. Haste Makes Care Unsafe. 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 Endnote tagged P…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49545/psn-pdf
    September 01, 2007 - Coming Undone: Failure of Closure Device September 1, 2007 Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device The Case A 65-year-old man underwent coronary angiography because of atypical exertional chest…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49440/psn-pdf
    March 01, 2004 - Autopsy Revelation March 1, 2004 Shojania KG. Autopsy Revelation. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/autopsy-revelation The Case A 45-year-old male with development delay presented to the emergency department with acute abdominal pain. His mother, who was his main caregiver, accompanied him. Th…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49470/psn-pdf
    December 01, 2004 - Discharge Fumbles December 1, 2004 Forster AJ. Discharge Fumbles. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/discharge-fumbles Case Objectives List the types of adverse events that occur at discharge Identify the characteristics that identify patients at high risk for errors at discharge Understand th…

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

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
    June 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case June 2007 Beeline to Spine Source and Credits This presentation is based on June 2007 AHRQ WebM&M Spotlight Case See full article at http://webmm.ahrq.gov CME credit is available online Commentary by: Gerald W. Smetana, MD, Harvard Medical School, Beth Israel D…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33724/psn-pdf
    February 01, 2012 - In Conversation With… Lawrence Smith, MD February 1, 2012 In Conversation With… Lawrence Smith, MD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-lawrence-smith-md Editor's note: Lawrence G. Smith, MD, is the founding Dean of Hofstra North Shore-LIJ School of Medicine and Executive Vice P…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49612/psn-pdf
    November 01, 2010 - Treatment Challenges After Discharge November 1, 2010 Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge Case Objectives Understand types and frequencies of adverse events occurring between patient discharge from the hospital …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49780/psn-pdf
    January 01, 2017 - The Missing Abscess: Radiology Reads in the Digital Era January 1, 2017 Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era Case Objectives Identify the most common complication of hysterectomy. Descr…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49582/psn-pdf
    April 01, 2009 - Breakage of a PICC Line April 1, 2009 Dimov V. Breakage of a PICC Line. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/breakage-picc-line Case Objectives Appreciate the incidence and consequences of PICC line breakage. Understand the risk factors for PICC line breakage. Understand the treatment options in…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857260/psn-pdf
    November 30, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! November 30, 2023 Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/when…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49547/psn-pdf
    October 01, 2007 - Code Blue—Where To? October 1, 2007 Adams BD. Code Blue—Where To? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/code-blue-where The Case An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was admitted to an inpatient psychiatry service for hallucinations and anxi…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72618/psn-pdf
    December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care December 23, 2020 https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards- medical-decisions Summary Nudges are a change in the way choices ar…

  16. In Conversation with...Diane Rydrych, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
    February 26, 2025 - In Conversation with...Diane Rydrych, MA June 1, 2007  Citation Text: In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.In Conversation with...Diane Rydrych, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49687/psn-pdf
    August 21, 2013 - Emergency Error August 21, 2013 Symons NRA. Emergency Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/emergency-error Case Objectives State that emergency surgery is high risk and has high mortality. Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33743/psn-pdf
    December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit December 1, 2012 Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit. PSNet [internet]. 2012. https://psnet.ahrq.gov…

  19. CYP450 Drugs: Expect the Unexpected | PSNet

    psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
    October 19, 2022 - CYP450 Drugs: Expect the Unexpected Citation Text: Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49609/psn-pdf
    October 01, 2010 - Dangerous Dialysis October 1, 2010 Holley JL. Dangerous Dialysis . PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/dangerous-dialysis Case Objectives List common errors that occur in dialysis units. Describe steps that can be taken by dialysis units to prevent these common errors. Describe the role of the …
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