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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49814/psn-pdf
    December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation Mishap December 1, 2017 Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap The Case A 63-year-old man with a history of coronary…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49832/psn-pdf
    June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error June 1, 2018 Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error The Case A 33-year-old woman with recently diagnosed acute …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49438/psn-pdf
    March 05, 2004 - OR Peeping March 1, 2004 Mackenzie CF. OR Peeping. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/or-peeping The Case A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete spontaneous abortion (miscarriage). At this community hospital, a new operating room (OR) su…
  4. psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
    May 01, 2019 - Electrocardiogram Results: ***READ ME*** Citation Text: Alpert JS. Electrocardiogram Results: ***READ ME***. 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 X3 XM…
  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
    January 01, 2020 - Spotlight Spotlight Inpatient Stroke Management in a Patient with Type 1 Diabetes and Home Insulin Pump Source and Credits • This presentation is based on the October 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: Berit B…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836942/psn-pdf
    April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room April 27, 2022 Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-m…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33741/psn-pdf
    November 01, 2012 - The Evidence-Based Physical Examination as a Patient Safety Practice November 1, 2012 McGee S. The Evidence-Based Physical Examination as a Patient Safety Practice. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice Perspective Near the end of hi…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49456/psn-pdf
    July 12, 2004 - Glucose Roller Coaster July 1, 2004 Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/glucose-roller-coaster The Case A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was significant for dialysis-dependent, end-stage kidney d…
  9. 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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33659/psn-pdf
    October 01, 2007 - Making Just Culture a Reality: One Organization's Approach October 1, 2007 Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach Perspective We've all been there...something goes wrong,…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49838/psn-pdf
    August 01, 2018 - An Untimely End Despite End-of-Life Care Planning August 1, 2018 Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning The Case A 76-year-old man was admitted to the intensive care unit (…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72624/psn-pdf
    January 05, 2021 - The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm January 5, 2021 https://psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework- reducing-inpatient-harm Summary Building on the company’s experience as a Hospital Engagement Network…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33727/psn-pdf
    March 01, 2012 - Can Research Help Us Improve the Medical Liability System? March 1, 2012 Kachalia A. Can Research Help Us Improve the Medical Liability System? PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system Perspective The United States medical malpractice liabili…
  14. psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
    December 15, 2024 - Medication Errors and Adverse Drug Events Citation Text: Medication Errors and Adverse Drug Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60790/psn-pdf
    February 23, 2022 - COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care February 23, 2022 Kalenderian E, Spallek H, Franklin A, et al. COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-oppor…
  16. psnet.ahrq.gov/perspective/emergence-application-based-healthcare
    August 05, 2022 - Emergence of Application-based Healthcare August 5, 2022  Also Read the Conversation View more articles from the same authors. Citation Text: Marvel FA, Dowell P, Mossburg SE. Emergence of Application-based Healthcare. PSNet [internet]. Rockville (MD): Agency fo…
  17. psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
    October 31, 2023 - In Conversation with... Cheryl Jones about Addressing Workplace Violence and Creating a Safer Workplace Cheryl B. Jones, PhD, RN, FAAN | October 31, 2023  Also Read the Essay View more articles from the same authors. Citation Text: Jones CB. In Conversation with…
  18. psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
    October 31, 2023 - Addressing Workplace Violence and Creating a Safer Workplace Cheryl B. Jones, PhD, RN, FAAN; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | October 31, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Jones CB, Sousane Z…
  19. psnet.ahrq.gov/perspective/conversation-francoise-marvel-md
    August 05, 2022 - In Conversation With... Francoise Marvel, MD August 5, 2022  Also Read the Essay Citation Text: In Conversation With.. Francoise Marvel, MD. PSNet [internet]. 2022.In Conversation With... Francoise Marvel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcar…
  20. psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
    April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance Lance L. Roberts, MS; Marcia M. Ward, PhD; Thomas C. Evans, MD | April 1, 2010  Also Read a Conversation View more articles from the same authors. …

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