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  1. 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…
  2. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
    January 01, 2015 - PowerPoint Presentation Spotlight Monitoring Fetal Health 1 This presentation is based on the January 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Mark W. Scerbo, PhD, Department of Psychology, Old Dominion University, and Alfred Z. Abuham…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33773/psn-pdf
    September 01, 2014 - Overuse as a Patient Safety Problem September 1, 2014 Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem Perspective Nearly half of primary care physicians in the United States believe that patients cared for in their own prac…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49405/psn-pdf
    June 01, 2003 - XL or Smaller? June 1, 2003 Kozer E. XL or Smaller? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/xl-or-smaller The Case With a history of hypertension and chronic renal failure secondary to hemolytic uremia syndrome at age 3, a 14-year-old boy presented to the emergency department with dehydration second…
  5. psnet.ahrq.gov/web-mm/misread-label
    August 28, 2024 - Misread Label Citation Text: Franklin BD. Misread Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49821/psn-pdf
    February 01, 2018 - Right Place, Right Drug, Wrong Strength February 1, 2018 Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength The Case A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49628/psn-pdf
    June 01, 2011 - Routine Goes Awry June 1, 2011 Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/routine-goes-awry The Case A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and scheduled for a tonsillectomy and adenoidectomy. She was in ot…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33687/psn-pdf
    August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care August 1, 2009 Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care Perspective Frontline health care providers are challen…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49812/psn-pdf
    November 01, 2017 - Specimen Almost Lost November 1, 2017 Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/specimen-almost-lost The Case A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen. She was admitted to the medicine service for further evalu…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33638/psn-pdf
    August 01, 2006 - Getting Into Patient Safety: A Personal Story August 1, 2006 Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/getting-patient-safety-personal-story Perspective My journey into patient safety began in 1972. It was born of serendipity enabled by the…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49551/psn-pdf
    December 01, 2007 - Too Hot For Comfort December 1, 2007 Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/too-hot-comfort The Case A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV antibiotics via a peripheral line in the left antec…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33821/psn-pdf
    December 01, 2016 - Errors and Near Misses: What Health Care Could Learn From Aviation December 1, 2016 Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation Perspective Some of the most urg…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33876/psn-pdf
    August 01, 2018 - Building a Safety Program in a Vast Health Care Network March 1, 2019 Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network Perspective Background As hospital-based health care in the United …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49595/psn-pdf
    December 01, 2009 - "Superficial" Report Leads to "Deep" Problem December 1, 2009 Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem The Case A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49617/psn-pdf
    January 01, 2011 - Failure to Reevaluate December 1, 2010 Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/failure-reevaluate The Case A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community hospital developed methicillin-resistant staphylococc…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49463/psn-pdf
    October 14, 2004 - Moved Too Soon October 1, 2004 Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/moved-too-soon The Case A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours after arriving, while the patient was still groggy from anesthesia, a nurs…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33676/psn-pdf
    November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH November 1, 2008 In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph Editor's note: Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49745/psn-pdf
    October 01, 2015 - Amphotericin Toxicity October 1, 2015 Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/amphotericin-toxicity The Case A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral posaconazole for residual fungal disease. She present…
  19. psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
    September 07, 2019 - Strategies and Approaches for Tracking Improvements in Patient Safety Citation Text: Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citat…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/612828/psn-pdf
    February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications February 23, 2022 Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications Objectives Recognition, early evaluation, and management of kidney …

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