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psnet.ahrq.gov/issue/quality-improvement-study-medication-error-leading-thyrotoxicosis-and-death
September 13, 2017 - Study
A quality improvement study: medication error leading to thyrotoxicosis and death.
Citation Text:
Levine JM. A quality improvement study: medication error leading to thyrotoxicosis and death. J Am Med Dir Assoc. 2004;5(6):410-3.
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psnet.ahrq.gov/issue/playing-it-safe-simulated-team-training-or
July 22, 2020 - Commentary
Playing it safe: simulated team training in the OR.
Citation Text:
Anderson M, Leflore J. Playing it safe: simulated team training in the OR. AORN J. 2008;87(4):772-9. doi:10.1016/j.aorn.2007.12.027.
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psnet.ahrq.gov/issue/addressing-structural-racism-pediatric-clinical-practice
November 16, 2022 - Commentary
Addressing structural racism in pediatric clinical practice.
Citation Text:
Laster M, Kozman D, Norris KC. Addressing structural racism in pediatric clinical practice. Pediatr Clin North Am. 2023;70(4):725-743. doi:10.1016/j.pcl.2023.03.010.
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psnet.ahrq.gov/issue/integrating-patient-safety-omfs-curriculum-survey-4-year-residency-programs
April 08, 2020 - Study
Integrating patient safety in the OMFS curriculum: survey of 4-year residency programs.
Citation Text:
Buhrow SM, Buhrow JA. Integrating Patient Safety in the OMFS Curriculum: Survey of 4-Year Residency Programs. J Patient Saf. 2016;12(4):197-203.
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…
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psnet.ahrq.gov/issue/safety-culture-indian-hospitals-cultural-adaptation-safety-attitudes-questionnaire
July 29, 2020 - Study
Safety culture in Indian hospitals: a cultural adaptation of the Safety Attitudes Questionnaire.
Citation Text:
Patel S, Wu AW. Safety Culture in Indian Hospitals: A Cultural Adaptation of the Safety Attitudes Questionnaire. J Patient Saf. 2016;12(2):75-81. doi:10.1097/PTS.00000000…
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psnet.ahrq.gov/issue/engineering-risk-analysis-hospital-oxygen-supply-system
July 23, 2014 - Commentary
Engineering risk analysis of a hospital oxygen supply system.
Citation Text:
Deleris LA, Yeo GL, Seiver A, et al. Engineering risk analysis of a hospital oxygen supply system. Med Decis Making. 2006;26(2):162-72.
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psnet.ahrq.gov/periodic-issue/periodic-issue-453
August 28, 2024 - August 21, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports…
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - July Syndrome
June 1, 2016
Young JQ. July Syndrome. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/july-syndrome
The Case
A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower
lobe lung cancer. The attending surgeon saw the patient along with his fellow,…
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psnet.ahrq.gov/node/33820/psn-pdf
December 01, 2016 - In Conversation With... James P. Bagian, MD, PE
December 1, 2016
In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
Editor's note: Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the
Uni…
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psnet.ahrq.gov/node/50696/psn-pdf
November 27, 2019 - Complications of Vascular Access Procedures in Patients
with Kidney Disease
November 27, 2019
Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
The Ca…
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psnet.ahrq.gov/web-mm/missing-point-eye-injury
March 01, 2005 - Missing the Point—Eye Injury
Citation Text:
Sharma R, Brunette DD. Missing the Point—Eye Injury. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/node/33675/psn-pdf
October 01, 2008 - Identifying Adverse Events Not Present on Admission:
Can We Do It?
October 1, 2008
Naessens JM. Identifying Adverse Events Not Present on Admission: Can We Do It? PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
Perspective
Interest is growi…
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psnet.ahrq.gov/node/836939/psn-pdf
April 27, 2022 - A Virtual Hospitalist Program to Address a Hospital’s
Challenges at the Start of the COVID-19 Pandemic
April 27, 2022
https://psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-
pandemic
Summary
In the early days of the COVID-19 pandemic, New York Presbyterian Weill …
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psnet.ahrq.gov/node/49457/psn-pdf
September 01, 2004 - Doctor, Don't Treat Thyself
September 1, 2004
Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
The Case
A 50-year-old radiologist presented to the emergency department of the community hospital where he
worked and reported increasing shortnes…
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication
Access Issue
April 1, 2014
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
The Case
A 24-year-old wom…
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psnet.ahrq.gov/node/49668/psn-pdf
October 01, 2012 - Buprenorphine and the Medically Ill Patient
October 1, 2012
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
The Case
A 60-year-old man with a 15-year history of oxycodone dependence presented to a substance …
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psnet.ahrq.gov/node/49426/psn-pdf
November 01, 2003 - Don't Push
November 1, 2003
Meltzer HY. Don't Push. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dont-push
The Case
A 37-year-old HIV-positive woman was brought to the emergency room by her family because she had
exhibited altered mentation for 3 days. The patient had been diagnosed with HIV infection 3 …
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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - Spotlight
Spotlight
"Do You Want Everything Done?":
Clarifying Code Status
Source and Credits
• This presentation is based on the December 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus
M…
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psnet.ahrq.gov/node/33733/psn-pdf
July 01, 2012 - Patient Safety and Health Information Technology:
Learning from Our Mistakes
July 1, 2012
Koppel R. Patient Safety and Health Information Technology: Learning from Our Mistakes. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
Perspe…
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psnet.ahrq.gov/node/49696/psn-pdf
December 01, 2013 - New Oral Anticoagulants
December 1, 2013
Fang MC. New Oral Anticoagulants. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/new-oral-anticoagulants
Case Objectives
Review properties of newer target-specific oral anticoagulants (TSOACs) such as dabigatran,
rivaroxaban, and apixaban.
State key perioperative c…