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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49748/psn-pdf
    December 01, 2015 - Managing Ascites: Hazards of Fluid Removal December 1, 2015 Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal The Case A 50-year-old man with longstanding alcoholic cirrhosis presented to the emergency department (ED) w…

  2. Spotlight Case (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
    August 01, 2012 - Spotlight Case Spotlight Case No News May Not Be Good News 1 2 Source and Credits This presentation is based on the August 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49515/psn-pdf
    July 01, 2006 - Over Not So Easy July 1, 2006 Cucina R. Over Not So Easy. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/over-not-so-easy The Case A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On admission, she reported allergies to a number of medications as well as a …

  4. Strategies and Approaches for Tracking Improvements in Patient Safety | PSNet

    psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
    June 15, 2024 - Strategies and Approaches for Tracking Improvements in Patient Safety Citation Text: Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citat…

  5. In Conversation with…Jack Barker, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withjack-barker-phd
    January 01, 2006 - In Conversation with…Jack Barker, PhD January 1, 2006  Also Read an Essay Citation Text: In Conversation with…Jack Barker, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy C…

  6. In Conversation With… Gregg S. Meyer, MD, MSc | PSNet

    psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
    June 01, 2016 - In Conversation With… Gregg S. Meyer, MD, MSc June 1, 2016  Also Read an Essay Also Read an Essay Citation Text: In Conversation With… Gregg S. Meyer, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health…

  7. 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…

  8. Harm From Alarm Fatigue | PSNet

    psnet.ahrq.gov/web-mm/harm-alarm-fatigue
    February 14, 2018 - SPOTLIGHT CASE Harm From Alarm Fatigue Citation Text: Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  9. Double Trouble | PSNet

    psnet.ahrq.gov/web-mm/double-trouble
    August 01, 2012 - SPOTLIGHT CASE Double Trouble Citation Text: Gurwitz JH. Double Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

  10. Delayed Recognition of a Positive Blood Culture | PSNet

    psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
    January 29, 2020 - Delayed Recognition of a Positive Blood Culture Citation Text: Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49588/psn-pdf
    August 01, 2009 - Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care August 1, 2009 Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care Case…

  12. Missed Patient Assignment: Is Anyone There? | PSNet

    psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
    September 01, 2017 - Missed Patient Assignment: Is Anyone There? Citation Text: Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33668/psn-pdf
    May 01, 2008 - In Conversation with…David W. Bates, MD, MSc May 1, 2008 In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and Quality …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49600/psn-pdf
    April 01, 2010 - Bad Writing, Wrong Medication April 1, 2010 Devine B. Bad Writing, Wrong Medication. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/bad-writing-wrong-medication Case Objectives Differentiate between a medication error and an adverse drug event. Appreciate the system complexities involved in medication erro…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60857/psn-pdf
    August 26, 2020 - Nothing Called Small Surgery August 26, 2020 Manske C. Nothing Called Small Surgery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/nothing-called-small-surgery The Case  A 56-year-old female presented to surgical clinic with pain and swelling in left great toe associated with progressive deformity of the …

  16. Innovations | PSNet

    psnet.ahrq.gov/innovations
    February 26, 2025 - Innovations The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …

  17. Dangerous Dialysis | PSNet

    psnet.ahrq.gov/web-mm/dangerous-dialysis
    June 12, 2024 - SPOTLIGHT CASE Dangerous Dialysis Citation Text: Holley JL. Dangerous Dialysis . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47578/psn-pdf
    November 28, 2018 - Identifying electronic health record usability and safety challenges in pediatric settings. November 28, 2018 Ratwani RM, Savage E, Will A, et al. Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings. Health Aff (Millwood). 2018;37(11):1752-1759. doi:10.1377/hlthaff.2018.0699. …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47524/psn-pdf
    June 19, 2019 - Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety. June 19, 2019 Giardina TD, Haskell H, Menon S, et al. Learning From Patients' Experiences Related To Diagnostic Errors Is Essential For Progress In Patient Safety. Health Aff (Millwood). 2018;37(11):1821-18…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45775/psn-pdf
    March 20, 2017 - A patient feedback reporting tool for OpenNotes: implications for patient–clinician safety and quality partnerships. March 20, 2017 Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient- clinician safety and quality partnerships. BMJ Qual Saf. 2016;26(4):312-3…
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