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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33644/psn-pdf
    December 01, 2006 - Establishing a Safety Culture: Thinking Small December 1, 2006 Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small Perspective Safety cultures are the holy grail in any risky industry. Like all holy grails, th…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49619/psn-pdf
    February 01, 2011 - Paradoxical Pulse February 1, 2011 Roy CL. Paradoxical Pulse. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/paradoxical-pulse The Case An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful pacemaker placement as an outpatient. The patient was restarted on …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33827/psn-pdf
    February 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS February 1, 2017 Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps Perspective Ten years ago, the Ag…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866847/psn-pdf
    September 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 25, 2024 Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Are…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867427/psn-pdf
    December 18, 2024 - The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls Falls are not a new issue, especially among older adults. The Centers for D…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49773/psn-pdf
    July 01, 2016 - Near Miss With Neonate October 1, 2016 Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/near-miss-neonate The Case A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxy…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73146/psn-pdf
    April 28, 2021 - Patient Safety in Home Dialysis April 28, 2021 Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/patient-safety-home-dialysis Dialysis Care and Patient Safety Concerns In patients with chronic kidney disease, kidney function declines ov…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33848/psn-pdf
    December 01, 2017 - The Evolution of Patient Safety in Surgery December 1, 2017 Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/evolution-patient-safety-surgery Perspective In 1979, 20 years before the Institute of Medicine's To Err Is Human report (1) catalyzed the cr…
  9. psnet.ahrq.gov/web-mm/lap-burn
    March 01, 2018 - Lap Burn Citation Text: Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…
  10. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
    August 01, 2009 - Spotlight Case July 2008 Spotlight Case Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care * Source and Credits This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME/CEU credit is available Commentary by: …
  11. psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
    January 01, 2020 - Spotlight Spotlight Suicidal Ideation in the Family Medicine Clinic 1 Source and Credits This presentation is based on the December 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Christine Moutier, MD, Chief Medical Officer, American …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49730/psn-pdf
    April 01, 2015 - Transition to Nowhere April 1, 2015 Farrell TW. Transition to Nowhere. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transition-nowhere The Case A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49656/psn-pdf
    June 01, 2012 - Comanagement: Who's in Charge? June 1, 2012 Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/comanagement-whos-charge The Case A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left hip fracture to the orthopedic surg…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49514/psn-pdf
    July 01, 2006 - One ACE Too Many July 1, 2006 Juurlink DN. One ACE Too Many. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/one-ace-too-many The Case A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure presented to the emergency department (ED) with chest pain. An acut…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49420/psn-pdf
    October 01, 2003 - To LP or Not LP October 1, 2003 Landrigan CP. To LP or Not LP. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lp-or-not-lp The Case A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with fever and irritability without an obvious source. He was referred to …
  16. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.164_slideshow.ppt
    December 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case December 2007 Elopement Source and Credits This presentation is based on the December 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Debra Gerardi, RN, MPH, JD Creighton University School of Law Ed…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33868/psn-pdf
    October 01, 2018 - Safety in the Retail Pharmacy October 1, 2018 Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/safety-retail-pharmacy Perspective There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each year.(1) Many patients interact w…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60548/psn-pdf
    May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020 In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food…
  19. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
    February 01, 2014 - PowerPoint Presentation Spotlight Case Multifactorial Medication Mishap 1 This presentation is based on the February 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Annie Yang, PharmD, BCPS NYU Langone Medical Center Editor, AHRQ WebM&M: Robe…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49867/psn-pdf
    July 02, 2019 - Diuretics and Electrolyte Abnormalities July 2, 2019 Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities Case Objectives Recognize that thiazide diuretics can lead to serious adverse events. State how commonly used t…

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