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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865454/psn-pdf
    March 27, 2024 - Ensuring Patient and Workforce Safety Culture in Healthcare March 27, 2024 Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare Introduction In 2020, the I…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50614/psn-pdf
    October 30, 2019 - In Conversation With… Vineet Chopra, MD, MSc October 30, 2019 In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc Editor's note: Dr. Chopra is Chief of the Division of Hospital Medicine and Associate Professor of Medicine at the…
  3. psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
    January 01, 2023 - • An orthopedic surgeon was consulted and recommended closed reduction of the left hip in the ED. … ” • The orthopedic surgeon performed the hip reduction successfully. 7 Case Details (4) • The
  4. psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
    May 01, 2019 - Electrocardiogram Results: ***READ ME*** Citation Text: Alpert JS. Electrocardiogram Results: ***READ ME***. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49574/psn-pdf
    November 01, 2008 - A Mid-Summer Fog November 1, 2008 Braddock CH. A Mid-Summer Fog. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/mid-summer-fog The Case A 33-year-old woman with type I diabetes mellitus was admitted for symptoms of left flank pain, dysuria, and emesis, concerning for pyelonephritis. The patient was taking …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49770/psn-pdf
    September 01, 2016 - Wrong-Time Error With High-Alert Medication September 1, 2016 Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication The Case A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
  7. psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
    June 24, 2020 - SPOTLIGHT CASE Fatal Error in Neonate: Does "Just Culture" Provide an Answer? Citation Text: Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …
  8. Spotlight (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.ppt
    November 01, 2018 - Spotlight Spotlight Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees * Source and Credits This presentation is based on the November 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Olle ten C…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49413/psn-pdf
    September 01, 2003 - Did We Forget Something? September 1, 2003 Gibbs VC. Did We Forget Something? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/did-we-forget-something The Case A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially attributed to ventilator-associated pneumo…
  10. 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…
  11. psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
    February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc October 30, 2019  Citation Text: In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867656/psn-pdf
    February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety February 26, 2025 Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
  13. psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
    September 01, 2006 - The surgeon had already destroyed two of these devices, and there was only one left in the whole OR suite
  14. psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
    November 01, 2018 - the hospital—patients rarely know their emergency medicine physician, their anesthesiologist, their surgeon … Under the Obama Administration, Medicare's top physician leader and the Surgeon General were both hospitalists
  15. psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
    November 01, 2018 - the hospital—patients rarely know their emergency medicine physician, their anesthesiologist, their surgeon … Under the Obama Administration, Medicare's top physician leader and the Surgeon General were both hospitalists
  16. psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
    May 01, 2017 - November 8, 2017 Surgeon-reported conflict with intensivists about postoperative goals … July 3, 2014 The role of surgeon error in withdrawal of postoperative life support.
  17. psnet.ahrq.gov/web-mm/check-wristband
    August 03, 2009 - don't know just how far this mistake would have gone, because the patient is frequently asleep when the surgeon
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49606/psn-pdf
    August 01, 2010 - with diabetes mellitus, hypertension, and obstructive sleep apnea (OSA) was referred to an orthopedic surgeon
  19. psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
    April 01, 2006 - A cardiovascular surgeon was consulted that day, and bypass surgery was scheduled for 4 days later.
  20. psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
    January 29, 2021 - cannot lie flat for the operation while breathing spontaneously, as is required for the ophthalmic surgeon

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