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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
    May 01, 2011 - Spotlight Case July 2008 Spotlight Case Duty to Disclose Someone Else’s Error * * Source and Credits This presentation is based on the May 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Thomas H. Gallagher, MD University of Washington …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49652/psn-pdf
    May 01, 2012 - Double Dose at Transfer May 1, 2012 Hackman JL. Double Dose at Transfer. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/double-dose-transfer The Case A 74-year-old man with history of diabetes and hypertension was admitted to the emergency department (ED) for left lower extremity pain, swelling, and erythe…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33798/psn-pdf
    January 01, 2015 - Accountability in Patient Safety January 1, 2015 Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/accountability-patient-safety Annual Perspective 2015 The tension between the no-blame culture espoused in the early years of the safety movement and …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33852/psn-pdf
    January 01, 2017 - Patient Engagement in Safety January 1, 2017 Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/patient-engagement-safety Annual Perspective 2017 Background In the past 2 decades, patient engagement in safety has evolved from obscurity to maturity. The Ins…
  5. psnet.ahrq.gov/web-mm/or
    August 22, 2013 - On O.R. Off? Citation Text: Leonard M. On O.R. Off?. 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 RIS Do…
  6. psnet.ahrq.gov/web-mm/triage-time-bomb
    September 01, 2008 - Triage Time Bomb Citation Text: Washington DL. Triage Time Bomb. 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/incomplete-orders-hypertonic-saline-treat-hyponatremia
    February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia Citation Text: Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation …
  8. psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
    May 16, 2022 - Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital Citation Text: Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from the Hospital.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
  9. psnet.ahrq.gov/web-mm/bleeding-risk
    November 01, 2003 - Bleeding Risk Citation Text: Crowther MA. Bleeding Risk. 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 tagged PubMedId RIS …
  10. psnet.ahrq.gov/web-mm/glucose-roller-coaster
    February 02, 2022 - Glucose Roller Coaster Citation Text: Sharpe B. Glucose Roller Coaster. 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 PubMed…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49583/psn-pdf
    April 01, 2009 - Eptifibatide Epilogue April 1, 2009 Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue The Case A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute coronary syndrome. Serial testing for mark…
  12. psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
    September 01, 2015 - Good Night's Sleep Gone Wrong Citation Text: Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. 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…
  13. psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
    January 12, 2011 - Team Training: Classroom Training vs. High-Fidelity Simulation Stephen D. Pratt, MD and Benjamin P. Sachs, MB | March 1, 2006  View more articles from the same authors. Citation Text: Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulatio…
  14. psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
    September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications Citation Text: Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49417/psn-pdf
    October 01, 2003 - Lost in the Black Hole October 1, 2003 Wachter R. Lost in the Black Hole. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lost-black-hole The Case A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis. She had a remote history of gonorrhea, no environmental exposu…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49775/psn-pdf
    November 01, 2016 - Unexpected Drawbacks of Electronic Order Sets November 1, 2016 McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets The Case A 70-year-old man with stage 4 prostate cancer presented to the emergency department …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49833/psn-pdf
    June 01, 2018 - Perils in Diagnosing a Stroke June 1, 2018 Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke The Case A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was brought to the emergency depart…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49433/psn-pdf
    June 23, 2021 - Environmental Safety in the OR February 1, 2004 Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/environmental-safety-or The Case The infection control department of a hospital noticed a marked increase in the rates of post-operative sternal wound inf…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49489/psn-pdf
    September 01, 2005 - Double Trouble September 1, 2005 Gurwitz JH. Double Trouble. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/double-trouble Case Objectives Appreciate the incidence of adverse drug events in older persons List preventative measures that can be used to minimize medication errors in this population Encourage…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49749/psn-pdf
    December 01, 2015 - Hyperglycemia and Switching to Subcutaneous Insulin December 1, 2015 Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin The Case A 47-year-old man with type 2 diabetes was admitted to the hospita…

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