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  1. psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
    May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap Citation Text: Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Forma…
  2. psnet.ahrq.gov/web-mm/bowel-prep
    March 01, 2017 - Bowel Prep Citation Text: Nelson D. Bowel Prep. 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 Endnote tagged PubMedId RIS Downloa…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848125/psn-pdf
    April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023 McGrath S, Blike G, Gale B, et al. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-…
  4. psnet.ahrq.gov/web-mm/collegiality-vs-competence
    August 28, 2024 - Collegiality vs. Competence Citation Text: Sagin T. Collegiality vs. Competence. 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 Endnote tagg…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49739/psn-pdf
    August 21, 2015 - Breathe Easy: Safe Tracheostomy Management August 21, 2015 Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management The Case A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49484/psn-pdf
    June 01, 2005 - Two Pills, Same Drug June 1, 2005 Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/two-pills-same-drug The Case A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past medical history included several AIDS-related complica…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49703/psn-pdf
    March 01, 2014 - After-Visit Confusion March 1, 2014 Ventres W. After-Visit Confusion. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/after-visit-confusion The Case An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white spots near her tongue. The patient's mother accompanied her …
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.182_slideshow.ppt
    September 01, 2008 - Spotlight Case July 2008 Spotlight Case Empiric Steroids: the Good, the Bad, and the Ugly Source and Credits This presentation is based on the September 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Edward D. Harris, Jr, MD, Stanford U…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49694/psn-pdf
    October 01, 2013 - Are You Mrs. A? An Issue of Identification Over Telephone October 1, 2013 Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone The Case Mr. A was a 78-year-old man admitted with non-ST elevation…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33751/psn-pdf
    January 01, 2014 - Strengthening the Business Case for Patient Safety May 1, 2013 Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety Perspective After more than a decade in the national spotlight, the problem of pati…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49815/psn-pdf
    December 01, 2017 - Over-the-Counter Oversight December 1, 2017 Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/over-counter-oversight The Case A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although portions of his skin we…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33881/psn-pdf
    August 01, 2019 - In Conversation With… Erik Hollnagel, PhD June 1, 2019 In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49674/psn-pdf
    December 01, 2012 - Preventing PICC Complications: Whose Line Is It? December 1, 2012 Moureau N. Preventing PICC Complications: Whose Line Is It? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it The Case A 55-year-old woman with myasthenia gravis, hypertension, and hypothyroidism prese…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867849/psn-pdf
    February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety In To Err I…
  15. psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
    September 23, 2024 - Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 11, 2021 Innovation …
  16. psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
    October 01, 2003 - Hospital Admission Due to High-Dose Methotrexate Drug Interaction Citation Text: Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Cit…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33772/psn-pdf
    September 01, 2014 - In Conversation With… Rosemary Gibson, MSc September 1, 2014 In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc Editor's note: Rosemary Gibson, MSc, is Senior Advisor to The Hastings Center and an editor for JAMA Internal Medicin…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72587/psn-pdf
    December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability December 23, 2020 Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49646/psn-pdf
    February 01, 2012 - Poorly Advanced Directives February 1, 2012 Anderson WG. Poorly Advanced Directives. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/poorly-advanced-directives The Case Cared for at home by his wife and family, an 82-year-old man with multiple chronic medical conditions described his overall health as decli…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49734/psn-pdf
    May 01, 2015 - Departure From Central Line Ritual May 1, 2015 Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/departure-central-line-ritual The Case A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…

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