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  1. The Ongoing Journey to Prevent Patient Falls | PSNet

    psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
    December 18, 2024 - Some research suggests that a patient’s perception of fall risk leads to behavioral changes that may

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857059/psn-pdf
    November 29, 2023 - variability.31 Although it is impossible to prevent all trans-hepatic PEG tube placements, one article suggests

  3. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet

    psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
    January 23, 2017 - In our opinion, this was a root cause of the error and suggests that both latent errors (i.e., related

  4. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients | PSNet

    psnet.ahrq.gov/web-mm/nonsustained-ventricular-tachycardia-after-acute-coronary-syndromes-recognizing-high-risk
    September 20, 2011 - Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients Citation Text: Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
    January 01, 2022 - Spotlight Spotlight Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis Source and Credits • This presentation is based on the November 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Narath Carlile MD MPH,…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49632/psn-pdf
    July 01, 2011 - A Seasonal Care Transition Failure July 1, 2011 Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure The Case A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine resident—for routine follow-up…

  7. Diuretics and Electrolyte Abnormalities | PSNet

    psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
    February 15, 2017 - Diuretics and Electrolyte Abnormalities Citation Text: Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49673/psn-pdf
    December 01, 2012 - A Real Heartache December 1, 2012 Polevoi SK. A Real Heartache. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/real-heartache The Case A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The pain began at rest, and it radiated to his back and left axilla. He had…

  9. Saved by ECMO | PSNet

    psnet.ahrq.gov/web-mm/saved-ecmo
    May 05, 2017 - Saved by ECMO Citation Text: Weiss NA. Saved by ECMO . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867849/psn-pdf
    February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety In To Err I…

  11. Is the Admission Drug Dose Too Low? | PSNet

    psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
    September 01, 2011 - Is the Admission Drug Dose Too Low? Citation Text: Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3…

  12. Specimen Almost Lost | PSNet

    psnet.ahrq.gov/web-mm/specimen-almost-lost
    September 21, 2022 - Specimen Almost Lost Citation Text: Hehe YK. Specimen Almost Lost. 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 XML Endnote tagged PubMedId RI…

  13. The Wild West: Patient Safety in Office-Based Anesthesia | PSNet

    psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
    April 01, 2003 - The Wild West: Patient Safety in Office-Based Anesthesia Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD | May 1, 2006  View more articles from the same authors. Citation Text: Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33751/psn-pdf
    January 01, 2014 - Strengthening the Business Case for Patient Safety May 1, 2013 Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety Perspective After more than a decade in the national spotlight, the problem of pati…

  15. Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx Spotlight Premature Closure: Was it Just Syncope? Source and Credits • This presentation is based on the November 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit i…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49484/psn-pdf
    June 01, 2005 - Two Pills, Same Drug June 1, 2005 Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/two-pills-same-drug The Case A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past medical history included several AIDS-related complica…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49710/psn-pdf
    May 01, 2014 - Discontinued Medications: Are They Really Discontinued? May 1, 2014 Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued The Case A 69-year-old man with a history of chronic atrial f…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33625/psn-pdf
    January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions Remain January 1, 2006 Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain Perspective On August 2, 2005, Air France flig…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49731/psn-pdf
    April 01, 2015 - Fire in the Hole!—An OR Fire April 1, 2015 Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/fire-hole-or-fire The Case A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection for a biopsy-proven adenocarcinom…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33666/psn-pdf
    October 01, 2008 - Methicillin-Resistant Staphylococcus aureus April 1, 2008 Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus Perspective Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
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