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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44957/psn-pdf
    March 09, 2016 - Government and industry fail to protect the public when they suggest "carefully following instructions" is enough to prevent vaccine errors. March 9, 2016 ISMP Medication Safety Alert! Acute care edition. February 25, 2016;21(4):1-5. https://psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-the…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837201/psn-pdf
    May 25, 2022 - Near miss research in the healthcare system: a scoping review. May 25, 2022 Feng T-ting, Zhang X, Tan L-ling, et al. Near miss research in the healthcare system: a scoping review. J Nurs Adm. 2022;52(3):160-166. doi:10.1097/nna.0000000000001124. https://psnet.ahrq.gov/issue/near-miss-research-healthcare-system-sco…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60152/psn-pdf
    March 25, 2020 - Errors during resuscitation: the impact of perceived authority on delivery of care. March 25, 2020 Delaloye NJ, Tobler K, O?Neill T, et al. Errors during resuscitation: the impact of perceived authority on delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.0000000000000359. https://psnet.ahrq.gov/issue/e…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43039/psn-pdf
    August 24, 2016 - How Doctors Think. August 24, 2016 Groopman J. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030. https://psnet.ahrq.gov/issue/how-doctors-think In this book, the author presents several stories that illustrate the forces that shape physician decision- making and may lead to diagnostic mistakes. Borrowing from …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34760/psn-pdf
    March 28, 2005 - Managing the Risks of Organizational Accidents. March 28, 2005 Reason JT. Aldershot, Hants, England: Ashgate: 1997. ISBN: 9781840141047 https://psnet.ahrq.gov/issue/managing-risks-organizational-accidents Written 7 years after the publication of Human Error, this book demonstrates Reason's thinking at its finest a…
  6. psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
    June 24, 2020 - SPOTLIGHT CASE Impatient Inpatient Dosing Citation Text: White RH. Impatient Inpatient Dosing. 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 E…
  7. psnet.ahrq.gov/web-mm/hidden-mystery
    December 01, 2011 - SPOTLIGHT CASE Hidden Mystery Citation Text: Brunette DD. Hidden Mystery. 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 …
  8. psnet.ahrq.gov/web-mm/crossing-line
    December 01, 2012 - SPOTLIGHT CASE Crossing the Line Citation Text: Feldman JP, Gould MK. Crossing the Line. 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…
  9. psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
    April 01, 2015 - SPOTLIGHT CASE Pseudo-obstruction But a Real Perforation Citation Text: Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33680/psn-pdf
    March 22, 2009 - In Conversation with...Dean Schillinger, MD March 22, 2009 In Conversation with..Dean Schillinger, MD. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md Editor's note: Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco, Directo…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33583/psn-pdf
    March 01, 2023 - Simulation Training March 1, 2023 Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/simulation-training Originally published in 2014 by researchers at the University of California, San Francisco. Updated in March 2023, by Jennifer J. Edwards, MS, RN, CHSE…
  12. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
    January 01, 2022 - Spotlight Spotlight Delayed Diagnosis of Mesenteric Ischemia Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Anamaria Robles, MD, and Garth Utter, MD, MSc o AHRQ WebM&M…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73200/psn-pdf
    April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions April 28, 2021 Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions The Case  A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and severe e…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865411/psn-pdf
    March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy March 27, 2024 Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49474/psn-pdf
    March 01, 2005 - Hidden Mystery March 1, 2005 Brunette DD. Hidden Mystery. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hidden-mystery Case Objectives Appreciate the challenges of caring for morbidly obese patients. List specific interventions that can be implemented when caring for obese patients. Develop a rational ap…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49684/psn-pdf
    May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical Error May 1, 2013 Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error Case Objectives Appreciate that chemotherapy a…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49708/psn-pdf
    May 01, 2014 - Medication Reconciliation With a Twist (or Dare We Say, a Patch?) May 1, 2014 Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch Case Objectives Appreciate that medication discrepanc…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33803/psn-pdf
    January 01, 2015 - In Conversation With… Richard Kronick, PhD February 1, 2014 In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since August 2013 …
  19. psnet.ahrq.gov/Information/Panel
    January 01, 2012 - Browse Author Resources Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
  20. psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
    January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging Citation Text: Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…

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