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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49842/psn-pdf
    September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33812/psn-pdf
    August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD August 1, 2016 In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd Editor's note: Dr. Perea-Pérez is Director de la Escuela de Medicina Legal y For…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49441/psn-pdf
    March 01, 2004 - Fumbled Handoff March 1, 2004 Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/fumbled-handoff The Case A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and chronic renal insufficiency was admitted for an elective sigmoid resect…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49503/psn-pdf
    February 01, 2006 - Workaround Error February 1, 2006 Pape T. Workaround Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/workaround-error The Case A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospita…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73146/psn-pdf
    April 28, 2021 - Patient Safety in Home Dialysis April 28, 2021 Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/patient-safety-home-dialysis Dialysis Care and Patient Safety Concerns In patients with chronic kidney disease, kidney function declines ov…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49530/psn-pdf
    February 01, 2007 - Rapid Mis-St(r)ep February 1, 2007 Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/rapid-mis-strep The Case A 5-year-old girl was brought to an urgent care center by her father with a 2-day history of fever to 103°F, sore throat, and diffuse abdominal pain. There was no history…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49467/psn-pdf
    December 01, 2004 - A "Weak" Response December 1, 2004 Reisman AB. A "Weak" Response. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/weak-response The Case A primary care physician on call for his group received a call at 9:00PM from a 68-year-old man. He said, "They started me on a new pill for my blood pressure and now I fe…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33735/psn-pdf
    August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It August 1, 2012 Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it Perspective At any point in time, …
  9. psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
    August 16, 2023 - Ruptured Heterotopic Pregnancy Citation Text: Cedars MI. Ruptured Heterotopic Pregnancy. 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 Endn…
  10. psnet.ahrq.gov/Webmm/submit-case-info
    August 10, 2025 - Selection Criteria and Honorarium Information How it works Health care professionals may submit de-identified cases that highlight medical errors or other patient safety/quality issues. Note that you can choose to submit cases either …
  11. psnet.ahrq.gov/primer/national-patient-safety-goals
    January 16, 2025 - National Patient Safety Goals Citation Text: Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
  12. psnet.ahrq.gov/primer/opioid-safety
    December 15, 2024 - Opioid Safety Citation Text: Opioid Safety. 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 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Ci…
  13. psnet.ahrq.gov/perspective/maternal-safety
    January 01, 2015 - Annual Perspective Maternal Safety Audrey Lyndon, RN, PhD | December 22, 2018  View more articles from the same authors. Citation Text: Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49682/psn-pdf
    April 01, 2013 - Availability The disposition to judge things as being more likely or frequently occurring, if they readily
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836794/psn-pdf
    March 31, 2022 - or used on patients” and relevant financial relationships as “financial relationships in any amount occurring
  16. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
    January 01, 2022 - . – The polyisoprene component of natural occurring latex forms cross-linkages that coagulate and stop
  17. psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
    April 03, 2024 - challenges that individuals and institutions face that often prevent robust medication reconciliation from occurring
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837215/psn-pdf
    July 08, 2022 - or used on patients” and relevant financial relationships as “financial relationships in any amount occurring
  19. psnet.ahrq.gov/web-mm/see-patient-first
    September 27, 2023 - culture if spike” is the most common anticipatory guidance communicated between inpatient providers, occurring
  20. psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
    January 01, 2023 - limitations on risky, blindly performed procedures could help to prevent complications of this type from occurring

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