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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33624/psn-pdf
    December 01, 2005 - In Conversation with…Troyen A. Brennan, MD, JD, MPH December 1, 2005 In Conversation with…Troyen A. Brennan, MD, JD, MPH. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph Dr. Robert Wachter, Editor, AHRQ WebM&M: What got you interested in the law and its interface…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49736/psn-pdf
    June 01, 2015 - Inflicting Confusion June 1, 2015 Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/inflicting-confusion The Case A 26-year-old man with recently diagnosed Crohn disease presented to the emergency department with acute-onset abdominal pain, nausea, vomiting, an…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73999/psn-pdf
    October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49459/psn-pdf
    September 01, 2004 - Caution, Interrupted September 1, 2004 Wears RL. Caution, Interrupted. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/caution-interrupted The Case A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and neutropenia presented to the emergency department (ED) with …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49401/psn-pdf
    May 01, 2003 - Suicidal Man With Gun May 1, 2003 Simon RI. Suicidal Man With Gun. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/suicidal-man-gun The Case The patient is a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe depression that had persisted for nearly 2 years. On initial inter…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851158/psn-pdf
    June 28, 2023 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization June 28, 2023 Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization The Case A patient was …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49466/psn-pdf
    October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49637/psn-pdf
    October 01, 2011 - The Dropped "No" October 1, 2011 Johnson AJ. The Dropped "No". PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropped-no The Case A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in his legs. Because the leg swelling was somewhat more pronounced in his…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49815/psn-pdf
    December 01, 2017 - Over-the-Counter Oversight December 1, 2017 Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/over-counter-oversight The Case A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although portions of his skin we…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49423/psn-pdf
    November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49711/psn-pdf
    June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of Patient Wandering June 1, 2014 Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering Case Objectives Define patie…
  12. psnet.ahrq.gov/training-catalog
    June 01, 2025 - Training Catalog The AHRQ PSNet Training Catalog is an easy to use resource for healthcare professionals across all settings of care and specialties looking for education opportunities to further their knowledge of patient safety practices and principles. Some training opportunities are available as in-person meeting…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49718/psn-pdf
    January 01, 2015 - Too Much, Too Fast September 1, 2014 Tuot D. Too Much, Too Fast. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/too-much-too-fast The Case A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for fever, tachycardia, and increased respiratory secretions. H…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49646/psn-pdf
    February 01, 2012 - Poorly Advanced Directives February 1, 2012 Anderson WG. Poorly Advanced Directives. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/poorly-advanced-directives The Case Cared for at home by his wife and family, an 82-year-old man with multiple chronic medical conditions described his overall health as decli…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49610/psn-pdf
    October 01, 2010 - "Recurrent" Appendicitis October 1, 2010 Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/recurrent-appendicitis The Case An 85-year-old man presented to the emergency department (ED) with right lower quadrant pain. On physical examination, the patient showed rebound t…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49776/psn-pdf
    November 01, 2016 - Continuity Errors in Resident Clinic November 1, 2016 Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic The Case A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty concentrating. …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49604/psn-pdf
    June 01, 2010 - Tacit Handover, Overt Mishap June 1, 2010 Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap The Case A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years earlier to treat an abdo…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49407/psn-pdf
    July 01, 2003 - Bleeding Risk July 1, 2003 Crowther MA. Bleeding Risk. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/bleeding-risk The Case A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial fibrillation, hypertension, coronary artery disease, and stroke. The surgi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49715/psn-pdf
    August 21, 2014 - Liver Biopsy: Proceed With Caution August 21, 2014 Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution The Case A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast cancer, presented t…
  20. psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
    October 27, 2021 - Study Classic Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Citation Text: Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…

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