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  1. 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…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865778/psn-pdf
    May 29, 2024 - Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement May 29, 2024 Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis Catheter Placement. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/navigating-complications-unint…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50928/psn-pdf
    February 21, 2020 - Updates in the Role of Health IT in Patient Safety February 21, 2020 Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety Background Health information technology (HIT) has the potential…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854897/psn-pdf
    October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose October 31, 2023 Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/weight-and-…

  5. The Safety Challenges of Supervision and Night Coverage in Academic Residency | PSNet

    psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
    February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency Citation Text: Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33678/psn-pdf
    January 01, 2009 - In Conversation with…Thomas H. Gallagher, MD January 1, 2009 In Conversation with…Thomas H. Gallagher, MD. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md Editor's note: Thomas H. Gallagher, MD, is Associate Professor in the Department of Medicine and the Departme…

  7. In Conversation with...Albert Wu, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
    February 26, 2025 - In Conversation with...Albert Wu, MD, MPH July 1, 2008  Citation Text: In Conversation with..Albert Wu, MD, MPH. PSNet [internet]. 2008.In Conversation with...Albert Wu, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74251/psn-pdf
    January 26, 2022 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest January 26, 2022 Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022. https…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72811/psn-pdf
    September 01, 2022 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors Originally published on March 3, 2021 Last updated on March 16, 2021 https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during- initial-treatment Summar…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49712/psn-pdf
    June 01, 2014 - May I Have Another?—Medication Error June 1, 2014 Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error The Case A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a pharmacology-tra…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49663/psn-pdf
    September 01, 2012 - Peripheral IV in Too Long September 1, 2012 Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long Case Objectives Appreciate the complications associated with peripheral intravenous (IV) catheters. Describe the optimal sterile technique that should be us…

  12. In Conversation With… Suchi Saria, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
    March 27, 2024 - In Conversation With… Suchi Saria, PhD July 1, 2019  Citation Text: In Conversation With… Suchi Saria, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49528/psn-pdf
    January 01, 2015 - The "Customer" Is Always Right February 1, 2007 Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/customer-always-right Case Objectives Understand the importance of identifying a patient's agenda. Appreciate the factors that contribute to unmet patient expectations. …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33746/psn-pdf
    March 01, 2013 - In Conversation With… David M. Gaba, MD March 1, 2013 In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of Medicine. An international leade…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49798/psn-pdf
    July 01, 2017 - Pseudo-obstruction But a Real Perforation July 1, 2017 Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation Case Objectives Recognize acute colonic pseudo-obstruction and implement a medical management plan. Ide…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49508/psn-pdf
    January 01, 2007 - Language Barrier April 1, 2006 Flores G. Language Barrier. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/language-barrier The Case A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish- speaking parents when they noted that their daughter had generalized we…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50949/psn-pdf
    February 26, 2020 - Pre-analytical pitfalls: Missing and mislabeled specimens February 26, 2020 Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens The Case Case #1: A 56-year-old man was admitted to…

  18. 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. …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33707/psn-pdf
    February 01, 2011 - The University of Texas System Clinical Safety and Effectiveness Course February 1, 2011 Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and Effectiveness Course. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…

  20. Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx Spotlight Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full …
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