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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50927/psn-pdf
    February 21, 2020 - Patient Safety in Primary Care February 21, 2020 Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/patient-safety-primary-care Introduction A strong primary care system is foundational to achieving high-quality, accessible, efficient healthcare …
  2. 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…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49444/psn-pdf
    May 01, 2004 - Do Me a Favor May 1, 2004 Williamson A. Do Me a Favor. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/do-me-favor The Case A 26-year-old gravida 4 para 1 woman reported that her last menstrual period was 5 weeks prior, and she had a positive home pregnancy test. With a history of one ectopic pregnancy, one…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49434/psn-pdf
    February 01, 2004 - Undiagnosed Vaginal Bleeding February 1, 2004 Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding The Case The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal bleeding. Over the past…
  5. 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…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49688/psn-pdf
    August 21, 2013 - Discharge Instructions in the PACU: Who Remembers? August 21, 2013 Engel KG. Discharge Instructions in the PACU: Who Remembers? PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers The Case A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in …
  7. 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…
  8. 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…
  9. 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…
  10. 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 …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49835/psn-pdf
    January 01, 2020 - Don't Pick the PICC July 1, 2018 McGill RL. Don't Pick the PICC. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/dont-pick-picc The Case A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy; glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
  12. psnet.ahrq.gov/web-mm/critical-opportunity-lost
    February 17, 2017 - Critical Opportunity Lost Citation Text: Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49517/psn-pdf
    August 01, 2006 - Miscalculated Risk August 1, 2006 Strassels SA. Miscalculated Risk. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/miscalculated-risk The Case A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2- week-old infant. He received Vicodin (hydrocodone and a…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33632/psn-pdf
    April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD (hon) April 1, 2006 In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background and how…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49797/psn-pdf
    June 01, 2017 - Diagnostic Overshadowing Dangers June 1, 2017 Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers The Case A 72-year-old woman with history of opioid abuse was sent to the emergency department (ED) from a methadone clinic because she a…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73999/psn-pdf
    October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49466/psn-pdf
    October 14, 2004 - Hard to Swallow October 1, 2004 Driver J. Hard to Swallow. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/hard-swallow The Case An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
  18. psnet.ahrq.gov/periodic-issue/periodic-issue-472
    February 26, 2025 - February 26, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, repor…
  19. psnet.ahrq.gov/web-mm/paradoxical-pulse
    May 01, 2013 - Paradoxical Pulse Citation Text: Roy CL. Paradoxical Pulse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  20. psnet.ahrq.gov/training-catalog
    June 01, 2025 - Training Catalog The AHRQ PSNet Training Catalog is an easy to use resource for healthcare professionals across all settings of care and specialties looking for education opportunities to further their knowledge of patient safety practices and principles. Some training opportunities are available as in-person meeting…

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