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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49442/psn-pdf
    May 01, 2004 - Missed TB May 1, 2004 FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/missed-tb The Case A 38-year-old white female with no past medical history presented to the hospital with fevers, respiratory failure, and bilateral pulmonary infiltrates. She was treated empirically w…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60168/psn-pdf
    March 25, 2020 - Right Electrocardiogram, Wrong Patient March 25, 2020 Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient The Cases Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33808/psn-pdf
    May 01, 2016 - Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue May 1, 2016 Jacques S, Williams E. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue Perspective Alarm fatigue occurs whe…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33797/psn-pdf
    January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice January 1, 2016 Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…

  5. 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…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33640/psn-pdf
    September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? September 1, 2006 Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…

  7. 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 …

  8. 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…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49700/psn-pdf
    February 01, 2014 - Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients February 1, 2014 Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/nonsustaine…

  10. 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 …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49755/psn-pdf
    February 01, 2016 - Good Night's Sleep Gone Wrong February 1, 2016 Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong The Case A 64-year-old woman came to the emergency department complaining of cough and shortness of breath, along with an…

  12. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
    February 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case February 2006 Lost in Transition Source and Credits This presentation is based on the February 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Christopher Beach, MD; Northwe…

  13. Spotlight Case (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
    August 01, 2012 - Spotlight Case Spotlight Case No News May Not Be Good News 1 2 Source and Credits This presentation is based on the August 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…

  14. Ruptured Heterotopic Pregnancy | PSNet

    psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
    August 16, 2023 - Ruptured Heterotopic Pregnancy Citation Text: Cedars MI. Ruptured Heterotopic Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  15. In Conversation With… Mary Dixon-Woods, DPhil | PSNet

    psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
    March 01, 2017 - This latter insight may strike some as a revolutionary idea; it suggests that different organizations

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73334/psn-pdf
    August 01, 2024 - In cases where IV push medication is prescribed, the ISMP suggests administering IV push medications

  17. Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
    January 01, 2023 - • In our opinion, this was a root cause of the error and suggests that both latent errors (i.e.,

  18. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication | PSNet

    psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
    August 01, 2012 - variability. 31 Although it is impossible to prevent all trans-hepatic PEG tube placements, one article suggests

  19. An Inadvertent Bolus of Norepinephrine. | PSNet

    psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
    December 04, 2016 - In cases where IV push medication is prescribed, the ISMP suggests administering IV push medications

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73899/psn-pdf
    September 29, 2021 - Lost in Transitions of Care: Managing an Opioid- Dependent Patient with Frequent Hospitalizations September 29, 2021 Tan F, Johl K, Kotova M. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/lost-transitions-care…
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