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  1. psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
    November 26, 2014 - SPOTLIGHT CASE Transfusion Thresholds in Gastrointestinal Bleeding Citation Text: Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citati…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73455/psn-pdf
    June 30, 2021 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks June 30, 2021 Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks The Case At the…
  3. psnet.ahrq.gov/web-mm/medication-mix-bad-worse
    March 01, 2018 - Medication Mix-Up: From Bad to Worse Citation Text: Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. 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 …
  4. psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
  5. psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
    October 02, 2019 - Continuity Errors in Resident Clinic Citation Text: Warm EJ. Continuity Errors in Resident Clinic. 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 …
  6. psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
    May 01, 2011 - SPOTLIGHT CASE The Wrong Shot: Error Disclosure Citation Text: Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Sch…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857259/psn-pdf
    November 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case  An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50928/psn-pdf
    February 21, 2020 - Updates in the Role of Health IT in Patient Safety February 21, 2020 Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety Background Health information technology (HIT) has the potential…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846563/psn-pdf
    March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March 2022 conviction of RaDonda Vaught, a former nu…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49402/psn-pdf
    June 01, 2003 - Inappropriate Antibiotic Use June 1, 2003 Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use The Case A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a first presentation of s…
  11. psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
    February 26, 2025 - In Conversation With... James P. Bagian, MD, PE December 1, 2016  Citation Text: In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.In Conversation With... James P. Bagian, MD, PE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research a…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33885/psn-pdf
    August 01, 2019 - In Conversation With… Susan Smith, MD August 1, 2019 In Conversation With… Susan Smith, MD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-susan-smith-md Editor's note: Dr. Smith, a family medicine physician, is chief faculty practices officer for UCSF Health. Over the past 3–4 years, the …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33822/psn-pdf
    January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA January 1, 2017 In Conversation With… Paul H. O'Neill, MPA. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa Editor's note: Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prio…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33663/psn-pdf
    September 15, 2008 - Implementing a Patient Safety Program at a Large National Health System January 1, 2008 Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system Perspectiv…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843151/psn-pdf
    February 01, 2023 - Patient Safety Concerns and the LGBTQ+ Population February 1, 2023 Wesley C, Van CM, Mossburg S. Patient Safety Concerns and the LGBTQ+ Population. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/patient-safety-concerns-and-lgbtq-population Challenges to Obtaining Needed Patient-Centered and Safe Health…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50949/psn-pdf
    February 26, 2020 - Pre-analytical pitfalls: Missing and mislabeled specimens February 26, 2020 Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens The Case Case #1: A 56-year-old man was admitted to…
  17. Spotlight (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
    January 01, 2019 - Spotlight Spotlight Mistaken Attribution, Diagnostic Misstep * Source and Credits This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD …
  18. 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…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33744/psn-pdf
    February 01, 2013 - In Conversation With… Beverley H. Johnson February 1, 2013 In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient- and Family-…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33805/psn-pdf
    April 01, 2016 - In Conversation With… Thomas J. Nasca, MD, MACP April 1, 2016 In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp Editor's note: Dr. Nasca is Chief Executive Officer of the Accreditation Council for Graduate Medical Educat…

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