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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49598/psn-pdf
    February 01, 2010 - Medication Reconciliation Pitfalls February 1, 2010 Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls The Case A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was brought to the eme…
  2. psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
    January 01, 2016 - Charcoal Lavage of the Lungs Citation Text: Wigton RS. Charcoal Lavage of the Lungs. 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 …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49730/psn-pdf
    April 01, 2015 - Transition to Nowhere April 1, 2015 Farrell TW. Transition to Nowhere. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transition-nowhere The Case A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49656/psn-pdf
    June 01, 2012 - Comanagement: Who's in Charge? June 1, 2012 Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/comanagement-whos-charge The Case A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left hip fracture to the orthopedic surg…
  5. psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx Spotlight When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Source and Credits • This presentation is based on the September 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psne…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49488/psn-pdf
    August 21, 2005 - PCA Overdose August 21, 2005 Doyle JD. PCA Overdose. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pca-overdose The Case A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo- oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33815/psn-pdf
    September 01, 2016 - Telemedicine and Patient Safety September 1, 2016 Agboola SO, Kvedar JC. Telemedicine and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/telemedicine-and-patient-safety Perspective A paradigm shift is ongoing in the health care sector. The traditional model of episodic and hospital-base…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49420/psn-pdf
    October 01, 2003 - To LP or Not LP October 1, 2003 Landrigan CP. To LP or Not LP. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lp-or-not-lp The Case A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with fever and irritability without an obvious source. He was referred to …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49505/psn-pdf
    March 01, 2006 - Collegiality vs. Competence March 1, 2006 Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/collegiality-vs-competence The Case A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective repair of a 10-cm abdominal aortic aneurys…
  10. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
    December 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case December 2007 Elopement Source and Credits This presentation is based on the December 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Debra Gerardi, RN, MPH, JD Creighton University School of Law Ed…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49577/psn-pdf
    January 01, 2009 - Are Two Insulin Pumps Better Than One? January 1, 2009 Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one The Case A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass graft surge…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60548/psn-pdf
    May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020 In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food…
  13. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
    February 01, 2014 - PowerPoint Presentation Spotlight Case Multifactorial Medication Mishap 1 This presentation is based on the February 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Annie Yang, PharmD, BCPS NYU Langone Medical Center Editor, AHRQ WebM&M: Robe…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49390/psn-pdf
    February 01, 2003 - Flying Object Hits MRI February 1, 2003 Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/flying-object-hits-mri The Case A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an anesthesiologist, the child was receiving…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49387/psn-pdf
    February 01, 2003 - Patient Mix-Up February 1, 2003 Shojania KG. Patient Mix-Up. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/patient-mix The Case Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general medical service at an academic medical center. Overnight, another man wit…
  16. psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
    March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events Citation Text: Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…
  17. psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
    December 22, 2018 - Annual Perspective Burnout Among Health Professionals and Its Effect on Patient Safety Audrey Lyndon, PhD | January 1, 2015  View more articles from the same authors. Citation Text: Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33593/psn-pdf
    June 15, 2024 - Measurement of Patient Safety June 15, 2024 Measurement of Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/measurement-patient-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866265/psn-pdf
    July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport July 31, 2024 MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
  20. psnet.ahrq.gov/primer/missed-nursing-care
    September 15, 2024 - Missed Nursing Care Citation Text: Missed Nursing Care. 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 …

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