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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38738/psn-pdf
    June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR. Hosp Pharm. 2009;44:463-464. https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-36 This monthly selection of error reports shares examples of topical anesthetic error, methotrexate overdose, and child-proof medicine cap dangers. https:…
  2. psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
    August 22, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH August 1, 2014  Also Read an Essay Citation Text: In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
  3. 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…
  4. 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…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40299/psn-pdf
    April 16, 2018 - Medication errors in the emergency department: need for pharmacy involvement? April 16, 2018 https://psnet.ahrq.gov/issue/medication-errors-emergency-department-need-pharmacy-involvement This piece reports on the prevalence of medication errors in the emergency department and suggests expanding pharmacy involvemen…
  6. psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
    September 26, 2012 - Amended Lab Results: Communication Slip Citation Text: Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  7. psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
    July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience Karen Frush, MD | May 1, 2005  View more articles from the same authors. Citation Text: Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49740/psn-pdf
    August 21, 2015 - Baffled by Botulinum Toxin August 21, 2015 Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/baffled-botulinum-toxin The Case A 5-year-old boy with a history of transverse myelitis with resultant spasticity of both lower extremities, gait abnormalities, neurogeni…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49507/psn-pdf
    April 01, 2006 - Is the "Surgical Personality" a Threat to Patient Safety? April 1, 2006 Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety? PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety Case Objectives Describe the myth of the "surgical personality" Identify featu…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49659/psn-pdf
    July 01, 2012 - Sloppy and Paste July 1, 2012 Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/sloppy-and-paste The Case A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new onset chest pain. The ED physician reviewed the patient's electronic me…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49487/psn-pdf
    August 21, 2005 - Surprise Wire August 21, 2005 Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/surprise-wire The Case A 39-year-old man with a history of liver disease presented to the emergency department (ED) with gastrointestinal bleeding and altered mental status. Due to his clinic…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49826/psn-pdf
    April 01, 2018 - Air on the Side of Caution April 1, 2018 Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/air-side-caution The Case A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of breath and chest pain. A decision was m…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49805/psn-pdf
    September 01, 2017 - The Forgotten Radiographic Read September 1, 2017 Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read The Case A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for management of inferior…
  14. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
    February 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case February 2006 Lost in Transition Source and Credits This presentation is based on the February 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Christopher Beach, MD; Northwe…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49742/psn-pdf
    September 01, 2015 - A Fumbled Handoff to Inpatient Rehab September 1, 2015 Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab The Case An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…
  16. Spotlight Case (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
    August 01, 2012 - Spotlight Case Spotlight Case No News May Not Be Good News 1 2 Source and Credits This presentation is based on the August 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…
  17. psnet.ahrq.gov/web-mm/communication-consultants
    October 01, 2018 - Communication With Consultants Citation Text: Cohn SL. Communication With Consultants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
  18. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
    March 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case March 2007 Failure to Report Source and Credits This presentation is based on the March 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33846/psn-pdf
    November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety November 1, 2017 Rozenblum R, Bates DW. The Role of Patient-facing Technologies to Empower Patients and Improve Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-imp…
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
    May 01, 2012 - Spotlight Case July 2008 Spotlight Case The Perils of Cross Coverage * * Source and Credits This presentation is based on the May 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …

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