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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73229/psn-pdf
    May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities May 26, 2021 Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
  2. psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
    October 01, 2013 - New Patient Mistakenly Checked in as Another Citation Text: Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…
  3. psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
    January 24, 2018 - Primary Workaround, Secondary Complication Citation Text: Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar B…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33709/psn-pdf
    July 01, 2011 - What Have We Learned About Safe Inpatient Handovers? March 1, 2011 Kripalani S. What Have We Learned About Safe Inpatient Handovers? PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers Perspective The care of hospitalized patients is marked by numerous tra…
  5. psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
    April 24, 2024 - Right Electrocardiogram, Wrong Patient Citation Text: Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49775/psn-pdf
    November 01, 2016 - Unexpected Drawbacks of Electronic Order Sets November 1, 2016 McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets The Case A 70-year-old man with stage 4 prostate cancer presented to the emergency department …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49512/psn-pdf
    May 01, 2006 - Right? Left? Neither! May 1, 2006 Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-left-neither Case Objectives Appreciate the role of Reason's Swiss Cheese Model in medical errors Understand the process of analyzing a single error Provide suggestions for …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33618/psn-pdf
    September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety September 1, 2005 Wachter R. Playing Well with Others: "Translocational Research" in Patient Safety. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety Perspective Translation…
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/system/systemredesignsafetynet/systemredesign.pptx
    July 01, 2014 - PowerPoint Presentation System Redesign for Value in Safety-Net Hospitals and Systems: Challenges and Implications Boston University School of Public Health prepared for Agency for Healthcare Research and Quality ACTION II The work reported here was done under AHRQ ACTION II Task Order Contract No. HHSA29020100002…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49640/psn-pdf
    November 01, 2011 - The Case for Patient Flow Management November 1, 2011 Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/case-patient-flow-management The Case A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse wa…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60609/psn-pdf
    June 24, 2020 - When the Indications for Drug Administration Blur June 24, 2020 Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur Disclosure of Relevant Financial Relationships: As a provider accredited by the Accre…
  12. psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
    November 21, 2021 - Lapse in Antibiotics Leads to Sepsis Citation Text: Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49458/psn-pdf
    September 01, 2004 - Poor Prognosis September 1, 2004 Lamont EB. Poor Prognosis. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/poor-prognosis Case Objectives Understand the current limitations of physicians' ability to provide prognoses. List the variables that can be used to guide treatment decisions and prognostication in e…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50612/psn-pdf
    October 30, 2019 - The Safety Challenges of Supervision and Night Coverage in Academic Residency October 30, 2019 Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency The Case…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846127/psn-pdf
    March 15, 2023 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists March 15, 2023 Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among- spec…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49554/psn-pdf
    January 01, 2008 - Chemotherapy Extravasation January 1, 2008 Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation The Case A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and her oncologist decided to begin sys…
  17. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/111-cusp-program-sustainability.docx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention CUSP Program: Sustainability ICU & Non-ICU Slide Title and Commentary Slide Number and Slide Program Sustainability SAY: Welcome to this presentation on optimizing CUSP Program sustainability as part of the overall approach to preventing MRSA in ICU and non-ICU settings. Sl…
  18. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/147-cusp-roles-responsibilities-tool.docx
    June 02, 2025 - AHRQ Safety Program for MRSA Prevention Core CUSP Team Member Roles & Responsibilities How To Use This Tool This tool identifies core Comprehensive Unit-based Safety Program (CUSP) team members and describes individual roles and responsibilities. For best results, each team member should: · Review expectations associa…
  19. psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
    December 18, 2019 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences Citation Text: Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…
  20. Psn-Pdf (pdf file)

    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…