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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49550/psn-pdf
    December 01, 2007 - patient safety indicators, their definitions, and technical specifications can be found in Appendix E of reference
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49673/psn-pdf
    December 01, 2012 - A Real Heartache December 1, 2012 Polevoi SK. A Real Heartache. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/real-heartache The Case A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The pain began at rest, and it radiated to his back and left axilla. He had…
  3. 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…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49718/psn-pdf
    January 01, 2015 - Too Much, Too Fast September 1, 2014 Tuot D. Too Much, Too Fast. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/too-much-too-fast The Case A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for fever, tachycardia, and increased respiratory secretions. H…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49625/psn-pdf
    May 01, 2011 - Pocket Syringe Swap May 1, 2011 Kulli JC. Pocket Syringe Swap. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/pocket-syringe-swap The Case A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for postoperative pain management. Surgery proceeded uneventfully under…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49486/psn-pdf
    August 21, 2005 - Impatient Inpatient Dosing August 21, 2005 White RH. Impatient Inpatient Dosing. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/impatient-inpatient-dosing Case Objectives Appreciate the challenges of initiating warfarin therapy in the hospitalized patient Understand the fundamental pharmacology of warfarin…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49846/psn-pdf
    November 01, 2018 - Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees November 1, 2018 Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-pr…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49695/psn-pdf
    October 01, 2013 - Finding Fault With the Default Alert October 1, 2013 Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/finding-fault-default-alert The Case A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital after experiencing …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49755/psn-pdf
    February 01, 2016 - Good Night's Sleep Gone Wrong February 1, 2016 Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong The Case A 64-year-old woman came to the emergency department complaining of cough and shortness of breath, along with an…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49826/psn-pdf
    April 01, 2018 - Air on the Side of Caution April 1, 2018 Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/air-side-caution The Case A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of breath and chest pain. A decision was m…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49564/psn-pdf
    July 01, 2008 - Dependence vs. Pain July 1, 2008 Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dependence-vs-pain Case Objectives Define opioid dependence and opioid withdrawal syndrome. Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid Withdra…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49819/psn-pdf
    February 01, 2018 - Signout Fallout February 1, 2018 Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/signout-fallout Case Objectives Understand the role of communication failures in medical errors and preventable adverse events. Review the evidence in support of handoff improvement pr…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49672/psn-pdf
    January 01, 2013 - The Lung Nodule That Refused To Grow December 1, 2012 Balekian AA, Gould MK. The Lung Nodule That Refused To Grow. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/lung-nodule-refused-grow Case Objectives Define a solitary pulmonary nodule. Identify the different initial first steps of management. Identify …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49450/psn-pdf
    June 01, 2004 - The Wrong Shot: Error Disclosure June 1, 2004 Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure Case Objectives Describe the rationale for disclosing harmful errors to patients. Describe the specific information that patie…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49543/psn-pdf
    September 01, 2007 - Medication Reconciliation: Whose Job Is It? September 1, 2007 Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it Case Objectives Appreciate the prevalence and impact of medication discrepancies at times of transition in …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49409/psn-pdf
    July 01, 2003 - Feeling No Pain July 1, 2003 Bogner MS. Feeling No Pain. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/feeling-no-pain The Case A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49716/psn-pdf
    August 21, 2014 - Benefits vs. Risks of Intraosseous Vascular Access August 21, 2014 Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access The Case A 72-year-old woman with a history of asthma, congestive heart…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49841/psn-pdf
    September 01, 2018 - Chemotherapy Administration Safety Standards September 1, 2018 Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards The Case A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49505/psn-pdf
    March 01, 2006 - Collegiality vs. Competence March 1, 2006 Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/collegiality-vs-competence The Case A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective repair of a 10-cm abdominal aortic aneurys…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49845/psn-pdf
    October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages October 1, 2018 Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages The Case A 1-month-old preterm infant in the ne…

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