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  1. 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…
  2. 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…
  3. 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…
  4. 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…
  5. 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 …
  6. 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…
  7. psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
    March 27, 2024 - In Conversation With… Suchi Saria, PhD July 1, 2019  Citation Text: In Conversation With… Suchi Saria, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  8. psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
    March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy Citation Text: Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar …
  9. 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…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836841/psn-pdf
    June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission April 7, 2022 https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and- paramedics-provide-home Sum…
  11. 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…
  12. 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 …
  13. 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…
  14. 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-…
  15. 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…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50392/psn-pdf
    September 01, 2019 - In Conversation With… Shantanu Agrawal, MD, MPhil September 1, 2019 In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil Editor's note: Dr. Agrawal is president and CEO of the National Quality Forum (NQF). He is the form…
  17. psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
    August 30, 2023 - Annual Perspective Impact of System Failures on Healthcare Workers George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD | March 21, 2023  View more articles from the same authors. Citation Text: Zangaro G, Van CM, Mossburg S. Imp…
  18. psnet.ahrq.gov/web-mm/low-totem-pole
    October 01, 2003 - SPOTLIGHT CASE Low on the Totem Pole Citation Text: Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33702/psn-pdf
    November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH November 1, 2010 In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
  20. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
    January 01, 2023 - Spotlight Spotlight Prolonged DKA in Pregnancy: A Case of Communication Breakdown Source and Credits • This presentation is based on the August 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarah Marshall, MD and Nina M. …

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