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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49781/psn-pdf
    January 01, 2017 - Hazards of Loading Doses January 1, 2017 Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-loading-doses The Case A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac arrest. Two days after discharg…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841468/psn-pdf
    December 14, 2022 - Don’t Bite Your Tongue. December 14, 2022 Singh NS. Don’t Bite Your Tongue. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/dont-bite-your-tongue The Case A 63-year-old woman with a past medical history of hypertension, osteoarthritis, migraine headaches, and daily smoking was admitted to a hospital for ant…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49505/psn-pdf
    March 01, 2006 - Collegiality vs. Competence March 1, 2006 Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/collegiality-vs-competence The Case A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective repair of a 10-cm abdominal aortic aneurys…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49839/psn-pdf
    August 01, 2018 - Mixup Beyond the Medication Label August 1, 2018 Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label The Case An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another hospi…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866265/psn-pdf
    July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport July 31, 2024 MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
  6. psnet.ahrq.gov/primer/missed-nursing-care
    September 15, 2024 - Missed Nursing Care Citation Text: Missed Nursing Care. 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 7 XML Endnote tagged PubMedId RIS …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33565/psn-pdf
    September 01, 2024 - Healthcare-associated Infections June 15, 2024 Healthcare - Associated Infections. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/health-care-associated-infections PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice …
  8. psnet.ahrq.gov/web-mm/informed-or-misled
    April 24, 2018 - Informed or Misled? Citation Text: White SM. Informed or Misled? . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
  9. psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
    November 02, 2016 - about traditional and professionalism-related patient safety threats: a national survey of interns and residents
  10. psnet.ahrq.gov/web-mm/beeline-spine
    March 01, 2014 - about traditional and professionalism-related patient safety threats: a national survey of interns and residents
  11. psnet.ahrq.gov/perspective/equity-patient-safety
    September 24, 2024 - (REParations and Anti-Institutional Racism) project includes faculty, students, staff, and medical residents
  12. psnet.ahrq.gov/webmm-case-studies
    March 25, 2025 - Workshops (1) Online Education (2) Patient Education (32) Residents
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60362/psn-pdf
    April 13, 2018 - low- and very low-birthweight babies in Arkansas (a state with a high poverty rate and many rural residents
  14. psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
    August 01, 2006 - So, we set out to interview anesthesiologists, residents, and nurse anesthetists, seeking to learn from
  15. psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
  16. psnet.ahrq.gov/web-mm/impact-communication-medication-errors
    August 01, 2009 - The Impact of Communication on Medication Errors Citation Text: Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: …
  17. psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
    March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety Sara J. Singer, MBA, PhD | September 1, 2013  View more articles from the same authors. Citation Text: Singer SJ. What We've Learned About Leveraging Leadership a…
  18. psnet.ahrq.gov/web-mm/dual-therapy-debacle
    February 01, 2007 - Dual Therapy Debacle Citation Text: Kayser SR. Dual Therapy Debacle. 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 X3 XML EndNote 7 XML Endnote tagged PubMedId …
  19. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
    March 01, 2009 - Spotlight Case July 2008 Spotlight Case All in the History Source and Credits This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Christopher Fee, MD, University of California, San Francisco …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49406/psn-pdf
    June 01, 2003 - The Dangerous Detour June 1, 2003 Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dangerous-detour The Case Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service for observation after being placed on a 72-hour hold by…

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