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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49389/psn-pdf
    February 01, 2003 - Procedural Mishap: Learning Curve? February 1, 2003 Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve The Case A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had undesired fert…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846922/psn-pdf
    March 29, 2023 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes March 29, 2023 https://psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions- and-improve-health Summary With increasing recognition that health is linked to the condit…
  3. psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
    February 26, 2025 - In Conversation With… Lorri Zipperer, MA November 1, 2015  Citation Text: In Conversation With… Lorri Zipperer, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49631/psn-pdf
    July 01, 2011 - Patient Safety and Adherence to Self-Administered Medications July 1, 2011 Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications The Case A 30-year-o…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49860/psn-pdf
    April 01, 2019 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement April 1, 2019 Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement The Case An 82-year-old man …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49473/psn-pdf
    March 01, 2005 - On O.R. Off? March 1, 2005 Leonard M. On O.R. Off? PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/or The Case An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting …
  7. 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…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49532/psn-pdf
    March 15, 2007 - Back to Basics March 1, 2007 Hellman R. Back to Basics. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/back-basics The Case A 48-year-old woman with insulin-dependent diabetes mellitus presents to the emergency department with right upper quadrant pain, fever, and leukocytosis, prompting admission for pres…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49587/psn-pdf
    May 01, 2009 - Missing Trauma May 1, 2009 Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/missing-trauma The Case A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a few minutes later by a customer, who immediately called 911. On arrival, para…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49395/psn-pdf
    April 01, 2003 - Medication Overdose April 1, 2003 Kaushal R. Medication Overdose. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/medication-overdose The Case A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He was diagnosed with status epilepticus and started on a loading…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49644/psn-pdf
    December 01, 2011 - Missing the Point—Eye Injury December 1, 2011 Sharma R, Brunette DD. Missing the Point—Eye Injury. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/missing-point-eye-injury The Case A 31-year-old woman presented to the emergency department (ED) after suffering multiple lacerations during an assault. The pati…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33684/psn-pdf
    May 01, 2009 - Patient Safety: A Perspective from Office Practice May 1, 2009 Baron RJ. Patient Safety: A Perspective from Office Practice. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice Perspective Most patient interactions with the health care system occur in the outpatien…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72624/psn-pdf
    January 05, 2021 - The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm January 5, 2021 https://psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework- reducing-inpatient-harm Summary Building on the company’s experience as a Hospital Engagement Network…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49556/psn-pdf
    March 01, 2008 - Hold That Order March 1, 2008 Grissinger M. Hold That Order. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/hold-order The Case A 25-year-old woman with a history of a pituitary tumor was admitted with hypernatremia. Because of her previous pituitary resection and radiation, the patient had a long history …
  15. 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…
  16. psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
    March 04, 2020 - The Hidden Harms of Hand Sanitizer Citation Text: Stewart S. The Hidden Harms of Hand Sanitizer. 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 XML EndNote 7 …
  17. psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
    December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005  View more articles from the same authors. Citation Text: Conway JB, Weingart SN. Organizational Change…
  18. psnet.ahrq.gov/web-mm/communication-consultants
    October 01, 2018 - Communication With Consultants Citation Text: Cohn SL. Communication With Consultants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
  19. psnet.ahrq.gov/innovation/critical-radiology-alert-process
    November 16, 2022 - Critical Radiology Alert Process Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL October 30, 2024 View more articles from the same authors. Innovation Contact …
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
    November 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case November 2006 Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Source and Credits This presentation is based on the November 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is…

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