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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866205/psn-pdf
    July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. July 10, 2024 Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hemorrhagic-sh…
  2. psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
    May 22, 2024 - SPOTLIGHT CASE How Do Providers Recover From Errors? Citation Text: West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar Bi…
  3. psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
    December 22, 2018 - SPOTLIGHT CASE Engaging Seriously Ill Older Patients in Advance Care Planning Citation Text: Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. …
  4. psnet.ahrq.gov/web-mm/breakage-picc-line
    June 21, 2023 - SPOTLIGHT CASE Breakage of a PICC Line Citation Text: Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  5. psnet.ahrq.gov/web-mm/discharging-our-responsibility
    January 16, 2019 - Discharging Our Responsibility Citation Text: Fonarow GC. Discharging Our Responsibility. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
  6. psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
    October 26, 2022 - Diagnosing a Missed Diagnosis Citation Text: Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…
  7. psnet.ahrq.gov/web-mm/mitigating-risk-intrahospital-transport-pediatric-patients-risk-physiologic-instability
    May 27, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability Citation Text: Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. Rockville (MD): Agency for Heal…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33637/psn-pdf
    August 01, 2006 - In Conversation with...Lucian Leape, MD August 1, 2006 In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withlucian-leape-md Dr. Robert Wachter, Editor, AHRQ WebM&M: What kind of career did you fashion for yourself prior to getting involved in safety an…
  9. psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
    October 10, 2017 - SPOTLIGHT CASE Discharged with IV antibiotics: When issues arise, who manages the complications? Citation Text: Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
  10. psnet.ahrq.gov/web-mm/july-syndrome
    July 01, 2011 - July Syndrome Citation Text: Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS D…
  11. psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
    October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters Citation Text: Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google S…
  12. psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
    June 24, 2010 - Methicillin-Resistant Staphylococcus aureus Gary A. Noskin, MD | April 1, 2008  View more articles from the same authors. Citation Text: Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73434/psn-pdf
    June 30, 2021 - The Consequences of Miscommunication Regarding a Possible Artifact June 30, 2021 Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact Disclosure of Relevant Financial Relationships…
  14. 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-…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33714/psn-pdf
    July 01, 2011 - In Conversation with…William B. Munier, MD, MBA July 1, 2011 In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba Editor's note: William B. Munier, MD, MBA, is the Director of the Center for Quality Improvement and Pati…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865656/psn-pdf
    April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous Combination April 24, 2024 Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination The Case A 26-ye…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33806/psn-pdf
    April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH April 1, 2016 In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics a…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33738/psn-pdf
    December 01, 2012 - In Conversation With... John G. Reiling, PhD December 1, 2012 In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with hospitals and…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49676/psn-pdf
    February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…

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