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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49492/psn-pdf
    November 01, 2005 - Reconciling Doses November 1, 2005 Federico F. Reconciling Doses. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/reconciling-doses Case Objectives List the steps involved in medication reconciliation. Describe the role of each of the stakeholders in medication reconciliation. Discuss how medication reconc…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49523/psn-pdf
    November 01, 2006 - Urinary Retention Dilemma November 1, 2006 Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma The Case Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy (BPH) and urinary hesitancy returned to th…
  3. psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
    February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3 Citation Text: Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49835/psn-pdf
    January 01, 2020 - Don't Pick the PICC July 1, 2018 McGill RL. Don't Pick the PICC. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/dont-pick-picc The Case A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy; glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
    July 01, 2012 - Spotlight Case July 2008 Spotlight Case Not-So-Therapeutic Tap * * Source and Credits This presentation is based on the July 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeffrey H. Barsuk, MD, MS; Northwestern University Feinberg Scho…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33845/psn-pdf
    November 01, 2017 - In Conversation With… Wanda Pratt, PhD November 1, 2017 In Conversation With… Wanda Pratt, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd Editor's note: Wanda Pratt is a Professor in the Information School with an adjunct appointment in the Division of Biomedical and …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49397/psn-pdf
    May 01, 2003 - The Dropped Lung May 1, 2003 Heffner JR. The Dropped Lung. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dropped-lung The Case A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49823/psn-pdf
    March 01, 2018 - Shortcuts to Acetaminophen-induced Liver Failure March 1, 2018 Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure The Case An 18-year-old woman, 27 weeks pregnant, presented to the emergency dep…
  9. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.85_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49722/psn-pdf
    December 01, 2014 - Medical Devices in the "Wild" December 1, 2014 Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/medical-devices-wild The Case A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes, chronic pain, arthritis, and…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33650/psn-pdf
    May 01, 2007 - Patient Safety in the United Kingdom: Evolution and Progress May 1, 2007 Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evolution and Progress. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress Perspective The dangers of health care in B…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33682/psn-pdf
    April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH April 1, 2009 In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph Editor's note: Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent s…
  13. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
    March 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case March 2005 The Hidden Mystery Source and Credits This presentation is based on the March 2005 AHRQ WebM&M Spotlight Case in Hospital Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Douglas D. Br…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50842/psn-pdf
    January 29, 2020 - Patient Identification Errors: A Systems Challenge January 29, 2020 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge The Cases The following four events involving five patients all involved…
  15. 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 …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33639/psn-pdf
    September 01, 2006 - In Conversation with...James P. Bagian, MD September 1, 2006 In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md Dr. Robert Wachter, Editor, AHRQ WebM&M: Where did your interest in safety come from? Dr. James Bagian: I don't know …
  17. 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…
  18. psnet.ahrq.gov/web-mm/workaround-error
    October 30, 2024 - Workaround Error Citation Text: Pape T. Workaround Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  19. psnet.ahrq.gov/primer/telehealth-and-patient-safety
    July 27, 2022 - Telehealth and Patient Safety. Citation Text: O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 …
  20. psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
    August 21, 2016 - Annual Perspective Rethinking Root Cause Analysis Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016  View more articles from the same authors. Citation Text: Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…

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