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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49437/psn-pdf
    March 01, 2004 - Crossing the Line March 1, 2004 Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/crossing-line Case Objectives Review complications of central venous catheterization Discuss patient and operator factors that affect complication rates Describe methods for preventing c…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49654/psn-pdf
    June 01, 2012 - Transfer Troubles June 1, 2012 Hains IM. Transfer Troubles. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients between hospitals is common. Understand the frequency of errors and adverse events in the transfer of patients between hospitals. …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860050/psn-pdf
    January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic Infant. January 4, 2024 Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant The Case A 2-month-old full-term male infant was b…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33736/psn-pdf
    September 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012 In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management at UCLA School of P…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49799/psn-pdf
    July 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49531/psn-pdf
    March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49741/psn-pdf
    September 01, 2015 - Abdominal Pain in Early Pregnancy September 1, 2015 Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy Case Objectives Recognize when nausea and vomiting in pregnancy is abnormal. Identify the most common causes of non-obstetric a…
  9. psnet.ahrq.gov/web-mm/double-trouble
    August 01, 2012 - SPOTLIGHT CASE Double Trouble Citation Text: Gurwitz JH. Double Trouble. 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 t…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49600/psn-pdf
    April 01, 2010 - Bad Writing, Wrong Medication April 1, 2010 Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication Case Objectives Differentiate between a medication error and an adverse drug event. Appreciate the system complexities involved in medication erro…
  11. psnet.ahrq.gov/web-mm/code-status-confusion
    September 01, 2006 - SPOTLIGHT CASE Code Status Confusion Citation Text: Lo B, Tulsky JA. Code Status Confusion. 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 EndN…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33710/psn-pdf
    May 01, 2011 - In Conversation with…Albert Wu, MD, MPH May 1, 2011 In Conversation with…Albert Wu, MD, MPH. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0 Editor's note: Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins School of Public Health. A…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49588/psn-pdf
    August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care August 1, 2009 Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care Case…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49608/psn-pdf
    August 01, 2010 - Emergent Triage Miss August 1, 2010 Travers D. Emergent Triage Miss. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/emergent-triage-miss The Case A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage nurse. The patient told the triage nurse that she had "3 days o…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33839/psn-pdf
    August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS August 1, 2017 In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwester…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33885/psn-pdf
    August 01, 2019 - In Conversation With… Susan Smith, MD August 1, 2019 In Conversation With… Susan Smith, MD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-smith-md Editor's note: Dr. Smith, a family medicine physician, is chief faculty practices officer for UCSF Health. Over the past 3–4 years, the …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33841/psn-pdf
    September 01, 2017 - In Conversation With… Andrew Gettinger, MD September 1, 2017 In Conversation With… Andrew Gettinger, MD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md Editor's note: Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the Office of Cli…
  18. psnet.ahrq.gov/web-mm/missed-appendicitis
    March 13, 2013 - SPOTLIGHT CASE Missed Appendicitis Citation Text: Adams JG. Missed Appendicitis. 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 E…
  19. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.281_slideshow.ppt
    October 01, 2012 - Spotlight Case July 2008 Spotlight Case CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure * * Source and Credits This presentation is based on the October 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Catherine L…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49602/psn-pdf
    April 01, 2010 - Anticoagulation: Held Too Long April 1, 2010 Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/anticoagulation-held-too-long The Case A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was admitted with abdominal pain. Because of the…

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