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  1. Pathologic Mistake | PSNet

    psnet.ahrq.gov/web-mm/pathologic-mistake
    February 15, 2010 - Pathologic Mistake Citation Text: Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49679/psn-pdf
    March 01, 2013 - The Unfamiliar Catheter March 1, 2013 Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/unfamiliar-catheter The Case A 28-year-old woman, 20 months post–bilateral lung transplant, presented to the emergency department with sudden onset of severe shortness of breath…

  3. Wrong Turn through Colon: Misplaced PEG | PSNet

    psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
    May 01, 2017 - Wrong Turn through Colon: Misplaced PEG Citation Text: Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote…

  4. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization | PSNet

    psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
    September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization Citation Text: Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49547/psn-pdf
    October 01, 2007 - Code Blue—Where To? October 1, 2007 Adams BD. Code Blue—Where To? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/code-blue-where The Case An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was admitted to an inpatient psychiatry service for hallucinations and anxi…

  6. Departure From Central Line Ritual | PSNet

    psnet.ahrq.gov/web-mm/departure-central-line-ritual
    October 13, 2018 - Departure From Central Line Ritual Citation Text: Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndN…

  7. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety | PSNet

    psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
    April 01, 2006 - Many of the Joint Commission's National Patient Safety Goals have grown out of our reports and recommendations

  8. Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care | PSNet

    psnet.ahrq.gov/web-mm/culture-clash-no-more-integration-and-coordination-disease-treatment-and-palliative-care
    December 23, 2020 - WebM&M Cases The Missing Suction Tip November 1, 2003 Recommendations

  9. Playing Well with Others: "Translocational Research" in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
    September 01, 2005 - Preventive Services Task Force, which often must make recommendations in the face of insufficient evidence

  10. In Conversation With… Alison Holmes, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
    March 01, 2014 - Public reporting of health care–associated surveillance data: recommendations from the Healthcare Infection

  11. In Conversation with…William B. Weeks, MD, MBA | PSNet

    psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
    May 01, 2009 - October 27, 2010 Opportunities and Recommendations for State–Federal Coordination to

  12. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
    January 01, 2021 - • Recommendations for reducing risks of errors associated with co-administration of multiple IV infusions

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33726/psn-pdf
    March 01, 2012 - The letter would summarize the issues in the case and the course of the case, but then include recommendations

  14. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-277
    February 10, 2021 - February 3, 2021 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, report…

  15. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-306
    August 25, 2021 - August 25, 2021 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…

  16. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-313
    October 27, 2021 - October 13, 2021 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, report…

  17. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-347
    May 16, 2022 - June 22, 2022 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, …

  18. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-413
    October 31, 2023 - October 18, 2023 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, report…

  19. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-374
    December 14, 2022 - January 18, 2023 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, report…

  20. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-379
    February 01, 2023 - February 22, 2023 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, repor…
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