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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837658/psn-pdf
    July 08, 2022 - Preventable Transfer to the Hospital July 8, 2022 Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/preventable-transfer-hospital The Case A 78-year-old veteran with dementia-associated aggressive behavior and multiple comorbidities had…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49518/psn-pdf
    August 01, 2006 - It's All in the Syringe August 1, 2006 Weingart SN. It's All in the Syringe. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/its-all-syringe The Case A 33-year-old man with type 2 diabetes presented to his physician's office to discuss his diabetes management. The patient admitted not taking his medications…
  3. psnet.ahrq.gov/web-mm/easily-forgotten-tube
    June 01, 2016 - An Easily Forgotten Tube Citation Text: Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49452/psn-pdf
    July 01, 2004 - Allergy to Holter July 1, 2004 Williams M. Allergy to Holter. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/allergy-holter The Case A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4 the patient was sent to the cardiac clinic to start a continuous …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33695/psn-pdf
    April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance April 1, 2010 Roberts LL, Ward MM, Evans TC. The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance. PSNet [internet]. 2010. ht…
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.368_slideshow.ppt
    February 01, 2016 - PowerPoint Presentation Spotlight Robotic Surgery: Risks vs. Rewards 1 Source and Credits This presentation is based on the February 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Tara Kirkpatrick, MD, and Chad LaGrange, MD, Univer…
  7. psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx Spotlight Premature Closure: Was it Just Syncope? Source and Credits • This presentation is based on the November 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit i…
  8. psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
    January 01, 2020 - Spotlight Too Many Cooks in the Kitchen Source and Credits • This presentation is based on the August 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Richard P. Dutton, MD, MBA o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
  9. psnet.ahrq.gov/web-mm/critical-opportunity-lost
    February 17, 2017 - Critical Opportunity Lost Citation Text: Genzen JR, Signorelli HN. Critical Opportunity Lost. 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 XML EndNote 7 XML…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49607/psn-pdf
    August 01, 2010 - Missed Patient Assignment: Is Anyone There? August 1, 2010 Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there The Case In one hospital, nurses' patient assignments were communicated by listing the…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33845/psn-pdf
    November 01, 2017 - In Conversation With… Wanda Pratt, PhD November 1, 2017 In Conversation With… Wanda Pratt, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd Editor's note: Wanda Pratt is a Professor in the Information School with an adjunct appointment in the Division of Biomedical and …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49538/psn-pdf
    June 01, 2007 - Abnormal Volunteer Results June 1, 2007 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results The Case A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent magnetic resonance imaging (MRI) of her abdo…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49784/psn-pdf
    February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care February 1, 2017 Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care The Case A 23-year-old woman presented to the family medicine clinic for…
  14. 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…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49711/psn-pdf
    June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of Patient Wandering June 1, 2014 Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering Case Objectives Define patie…
  16. psnet.ahrq.gov/web-mm/workaround-error
    October 30, 2024 - Workaround Error Citation Text: Pape T. Workaround Error. 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 tagged PubMedId RIS …
  17. psnet.ahrq.gov/primer/telehealth-and-patient-safety
    July 27, 2022 - Telehealth and Patient Safety. Citation Text: O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33699/psn-pdf
    August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers August 1, 2010 Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers Perspective Academic medical…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49569/psn-pdf
    September 01, 2008 - Where's the Feeding Tube? September 1, 2008 Metheny NA, Meert KL. Where's the Feeding Tube? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/wheres-feeding-tube The Case A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury. Because of the injuries, he was unabl…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49407/psn-pdf
    July 01, 2003 - Bleeding Risk July 1, 2003 Crowther MA. Bleeding Risk. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/bleeding-risk The Case A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial fibrillation, hypertension, coronary artery disease, and stroke. The surgi…

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