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2061. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49699/psn-pdf
      February 01, 2014 - Multifactorial Medication Mishap February 1, 2014 Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Id…

2062. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50392/psn-pdf
      September 01, 2019 - In Conversation With… Shantanu Agrawal, MD, MPhil September 1, 2019 In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil Editor's note: Dr. Agrawal is president and CEO of the National Quality Forum (NQF). He is the form…

2063. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/852808/psn-pdf
      August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication Breakdown. August 30, 2023 Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown Disclosure of Relevant Financial Relationship…

2064. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33652/psn-pdf
      June 01, 2007 - Advancing Patient Safety Through State Reporting Systems June 1, 2007 Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems Perspective Seven years ago, the Institute of Medicine (I…

2065. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49437/psn-pdf
      March 01, 2004 - Crossing the Line March 1, 2004 Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/crossing-line Case Objectives Review complications of central venous catheterization Discuss patient and operator factors that affect complication rates Describe methods for preventing c…

2066. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33643/psn-pdf
      December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA December 1, 2006 In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and Critic…

2067. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33774/psn-pdf
      December 01, 2014 - In Conversation With… Edward Kelley, PhD December 1, 2014 In Conversation With… Edward Kelley, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-edward-kelley-phd Editor's note: Edward Kelley, PhD, is Director of Service Delivery and Safety for the World Health Organization (WHO). He ha…

2068. Personal Health Literacy | PSNet
      psnet.ahrq.gov/primer/personal-health-literacy
      October 31, 2023 - Personal Health Literacy Citation Text: Bakerjian D. Personal Health Literacy. 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…

2069. Are We Getting Better at Measuring Patient Safety? | PSNet
      psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
      November 10, 2015 - Are We Getting Better at Measuring Patient Safety? Amy K. Rosen, PhD | November 1, 2010  View more articles from the same authors. Citation Text: Rosen AK. Are We Getting Better at Measuring Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare R…

2070. Continuing Education | PSNet
      psnet.ahrq.gov/continuing-education
      February 26, 2025 - Continuing Education What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…

2071. Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax | PSNet
      psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
      December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax Citation Text: Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …

2072. Complaints as Safety Surveillance | PSNet
      psnet.ahrq.gov/web-mm/complaints-safety-surveillance
      May 05, 2021 - Complaints as Safety Surveillance Citation Text: Morris JL, Bismark M. Complaints as Safety Surveillance. 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 E…

2073. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49402/psn-pdf
      June 01, 2003 - Inappropriate Antibiotic Use June 1, 2003 Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use The Case A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a first presentation of s…

2074. Failure to Latch | PSNet
      psnet.ahrq.gov/web-mm/failure-latch
      November 27, 2012 - Failure to Latch Citation Text: Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

2075. Burnout | PSNet
      psnet.ahrq.gov/primer/burnout
      November 20, 2024 - Burnout Citation Text: Yellowlees P, Rea M. Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Do…

2076. 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…

2077. Inappropriate Antibiotic Use | PSNet
      psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
      September 22, 2010 - Inappropriate Antibiotic Use Citation Text: Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

2078. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! | PSNet
      psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
      February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! Citation Text: Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…

2079. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
      January 01, 2024 - Spotlight Spotlight A Fatal Twist in Pseudohyperkalemia 1 Source and Credits This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…

2080. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33599/psn-pdf
      August 30, 2023 - Personal Health Literacy August 30, 2023 Bakerjian D. Personal Health Literacy. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/personal-health-literacy Originally published in July 2017 by researchers at the University of California, San Francisco. Updated in August 2023 by Deb Bakerjian, PhD, RN, APRN, FAA…