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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33580/psn-pdf
    April 01, 2022 - Nursing and Patient Safety April 21, 2021 Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/nursing-and-patient-safety Updated in March 2021. Originally published in December 2011 by researchers at the University of California, San Francisco.  …
  2. psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
    January 13, 2021 - Delayed Sepsis Management Due to Ambiguous Allergy Citation Text: Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Schol…
  3. psnet.ahrq.gov/web-mm/lost-transition
    November 17, 2010 - SPOTLIGHT CASE Lost in Transition Citation Text: Beach C. Lost in Transition. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
  4. psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
    March 01, 2004 - SPOTLIGHT CASE The Lung Nodule That Refused To Grow Citation Text: Balekian AA, Gould MK. The Lung Nodule That Refused To Grow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Googl…
  5. psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
    May 01, 2018 - SPOTLIGHT CASE Medication Reconciliation: Whose Job Is It? Citation Text: Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Googl…
  6. psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
    September 01, 2007 - SPOTLIGHT CASE Out of Sight, Out of Mind: Out-of-Office Test Result Management Citation Text: Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
  7. psnet.ahrq.gov/sites/default/files/2023-01/spotlight_respiratory_distress_after_neck_surgery_two_cases_of_postoperative_cervical_hematoma.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Postop Cervical Hematomas_12.15.2022 FINAL.pptx Spotlight Respiratory Distress after Neck Surgery: Two Cases of Post-Operative Cervical Hematoma Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotlight Case o See the full article at https://…
  8. psnet.ahrq.gov/web-mm/compare-and-contrast
    July 16, 2019 - SPOTLIGHT CASE Compare and Contrast Citation Text: Cho KC, Chertow GM. Compare and Contrast. 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 End…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865411/psn-pdf
    March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy March 27, 2024 Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
  10. psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
    August 01, 2005 - The Unfinished Patient Safety Agenda Linda H. Aiken, PhD, RN | August 1, 2005  Also Read a Conversation View more articles from the same authors. Citation Text: Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. Rockville (MD): Agency for Healthc…
  11. psnet.ahrq.gov/web-mm/novel-drug-misuse
    September 30, 2010 - SPOTLIGHT CASE Novel Drug Misuse Citation Text: Angus DC, Milbrandt EB. Novel Drug Misuse. 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 EndNo…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852698/psn-pdf
    August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation August 30, 2023 https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and- diagnostic-accuracy Summary Addressing diagnostic errors to improve outcomes and patient safety h…
  13. psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
    November 16, 2022 - Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure. Citation Text: Partridge E, Dodson D, Reilly M, et al. Aspergillus Mediastinitis & Endocarditis in a Pediatric Patient Complicating Cardiac Surgery and Bedside Chest Closure.. PSNet [inter…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49478/psn-pdf
    April 01, 2005 - Compare and Contrast April 1, 2005 Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/compare-and-contrast Case Objectives Define contrast nephropathy (CN) List risk factors for CN Implement pharmacologic strategies for CN prophylaxis Follow an algorithm for CN risk …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49834/psn-pdf
    July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety July 1, 2018 Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety Case Objectives Unders…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49810/psn-pdf
    November 01, 2017 - Palliative Care: Comfort vs. Harm November 1, 2017 Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm Case Objectives Recognize errors may be difficult to identify in palliative care. State that medication errors and errors in communica…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49729/psn-pdf
    April 01, 2015 - Dissecting the Presentation April 1, 2015 Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/dissecting-presentation Case Objectives Define aortic dissection. Describe the epidemiology of acute aortic dissection. State the common and uncommon presentation of acute aor…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49822/psn-pdf
    March 01, 2018 - Isolated Clot, Real Error March 1, 2018 Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/isolated-clot-real-error Case Objectives Appreciate that errors are common in the management of venous thromboembolism disease. Describe patients with venous thromboembolism i…
  19. psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
    March 15, 2023 - E-cigarette Explosion in a Patient Room Citation Text: Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…
  20. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
    January 01, 2022 - Spotlight Spotlight Delayed Diagnosis of Mesenteric Ischemia Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc o AHRQ WebM&M…

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