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  1. psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
    October 10, 2017 - SPOTLIGHT CASE Discharged with IV antibiotics: When issues arise, who manages the complications? Citation Text: Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
  2. psnet.ahrq.gov/web-mm/who-nose-where-airway
    May 01, 2016 - Who Nose Where the Airway Is? Citation Text: Lee CR. Who Nose Where the Airway Is?. 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 XML EndNote 7 XML Endnote t…
  3. psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
    May 01, 2011 - SPOTLIGHT CASE The Wrong Shot: Error Disclosure Citation Text: Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Sch…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49570/psn-pdf
    October 01, 2008 - Recurrent Hypoglycemia: A Care Transition Failure? October 1, 2008 Eytan T. Recurrent Hypoglycemia: A Care Transition Failure? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure Case Objectives Understand the complementary abilities of an electronic health record a…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846563/psn-pdf
    March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March 2022 conviction of RaDonda Vaught, a former nu…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49639/psn-pdf
    November 01, 2011 - Near Miss with Bedside Medications November 1, 2011 Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications Case Objectives Understanding the definition of near miss—also known as close call. Appreciate the importance of close calls in reducin…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49865/psn-pdf
    June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy June 1, 2019 Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy The Case A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848109/psn-pdf
    April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride Extravasation. April 26, 2023 The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation The Case A 52-year-old man with a history of lymphoplasmacytic lymph…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49712/psn-pdf
    June 01, 2014 - May I Have Another?—Medication Error June 1, 2014 Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error The Case A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a pharmacology-tra…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49732/psn-pdf
    May 01, 2015 - Errors in Sepsis Management May 1, 2015 Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/errors-sepsis-management Case Objectives Define sepsis, severe sepsis, and septic shock. Describe the severe sepsis/septic shock resuscitation bundle. Recognize commonly encou…
  11. psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
    March 27, 2024 - In Conversation With… Suchi Saria, PhD July 1, 2019  Citation Text: In Conversation With… Suchi Saria, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33663/psn-pdf
    September 15, 2008 - Implementing a Patient Safety Program at a Large National Health System January 1, 2008 Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system Perspectiv…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49798/psn-pdf
    July 01, 2017 - Pseudo-obstruction But a Real Perforation July 1, 2017 Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation Case Objectives Recognize acute colonic pseudo-obstruction and implement a medical management plan. Ide…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50949/psn-pdf
    February 26, 2020 - Pre-analytical pitfalls: Missing and mislabeled specimens February 26, 2020 Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens The Case Case #1: A 56-year-old man was admitted to…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49859/psn-pdf
    April 01, 2019 - E-cigarette Explosion in a Patient Room April 1, 2019 Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room The Case A 49-year-old woman was admitted for an exacerbation of chronic obstructive pulmonary disease (COPD) without…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49450/psn-pdf
    June 01, 2004 - The Wrong Shot: Error Disclosure June 1, 2004 Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure Case Objectives Describe the rationale for disclosing harmful errors to patients. Describe the specific information that patie…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49480/psn-pdf
    May 01, 2005 - Diagnosing Diagnostic Mistakes May 1, 2005 McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes Learning Objectives Understand the biases that may contribute to overcalling medical errors Describe the impact of conside…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49606/psn-pdf
    August 01, 2010 - Weighing In on Surgical Safety August 1, 2010 Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/weighing-surgical-safety Case Objectives Identify the comorbidites associated with obesity that place patients at higher risk for surgical complications. Un…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49485/psn-pdf
    August 29, 2024 - Blind Spot June 1, 2005 Lee LA. Blind Spot. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/blind-spot The Case A 36-year-old woman with no significant past medical history underwent right nephrectomy in the left lateral position. The surgery was uncomplicated—her blood pressures intraoperatively were withi…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867985/psn-pdf
    January 01, 2025 - Suicide Prevention March 25, 2025 Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024. https://psnet.ahrq.gov/perspective/suicide-prevention Introduction Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in 2022, a 36% rise since 2000…

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