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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50843/psn-pdf
    January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia January 29, 2020 Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia The Case A 54-year-old man was brought t…

  2. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
    September 01, 2012 - Spotlight Case July 2008 Spotlight Case Peripheral IV in Too Long 1 2 Source and Credits This presentation is based on the September 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Chi-Tai Fang, MD, PhD; Associate Professor, National Taiwan Uni…

  3. Hazards of Loading Doses | PSNet

    psnet.ahrq.gov/web-mm/hazards-loading-doses
    December 01, 2003 - Hazards of Loading Doses Citation Text: Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. 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 E…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49761/psn-pdf
    May 01, 2016 - The Fluidity of Diagnostic "Wet Reads" May 1, 2016 Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads The Case A 64-year-old man with heavy tobacco use presented to the emergency department (ED) with chest pain. His electroc…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33705/psn-pdf
    January 01, 2011 - Risk Management and Patient Safety December 1, 2010 Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety Perspective In 1990, a Harvard-based research team reported the incidence of medical errors …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49622/psn-pdf
    March 01, 2011 - Dropping the Ball Despite an Integrated EMR March 1, 2011 Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr The Case A patient followed at a community-based clinic that is part of a large health care system with an in…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33581/psn-pdf
    December 15, 2024 - Medication Errors and Adverse Drug Events December 15, 2024 Medication Errors and Adverse Drug Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect cu…

  8. The Weekend Effect | PSNet

    psnet.ahrq.gov/perspective/weekend-effect
    April 01, 2008 - Annual Perspective The Weekend Effect Sumant Ranji, MD | January 1, 2017  View more articles from the same authors. Citation Text: Ranji SR. The Weekend Effect. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Hea…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49572/psn-pdf
    October 01, 2008 - Mistaken Identity October 1, 2008 Hall LW. Mistaken Identity. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/mistaken-identity The Case An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status and a reported fall. After finding tenderness in her left hip, the p…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49808/psn-pdf
    October 01, 2017 - High-Risk Medications, High-Risk Transfers October 1, 2017 Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers The Case A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49502/psn-pdf
    February 01, 2006 - Deciphering the Code February 1, 2006 Goldstein MK. Deciphering the Code. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/deciphering-code The Case An 85-year-old man with advanced oxygen-dependent chronic obstructive pulmonary disease (COPD) presented to the emergency department (ED) with increasing shortn…

  12. Improving Patient Safety and Team Communication through Daily Huddles | PSNet

    psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
    December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles Citation Text: Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citatio…

  13. Back to Basics | PSNet

    psnet.ahrq.gov/web-mm/back-basics
    July 13, 2010 - Back to Basics Citation Text: Hellman R. Back to Basics. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  14. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
    January 01, 2024 - – In addition, further evaluation of blood pressure and laboratory test results against the Phoenix

  15. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

    psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
    September 24, 2024 - And let us say there’s no way to test for it.

  16. In Conversation With... Cindy Brach | PSNet

    psnet.ahrq.gov/perspective/conversation-cindy-brach
    December 27, 2019 - In Conversation With... Cindy Brach December 27, 2019  Also Read the Essay Citation Text: In Conversation With.. Cindy Brach. PSNet [internet]. 2019.In Conversation With... Cindy Brach. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841305/psn-pdf
    January 27, 2023 - Sarah Mossburg: It sounds like simulation really allows people to test adaptations to situations and

  18. Which Line: Ordering Provider or Proceduralist? | PSNet

    psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
    September 16, 2015 - Self-check will not help as the provider lacks the understanding of the preferred imaging test.

  19. Privacy or Safety? | PSNet

    psnet.ahrq.gov/web-mm/privacy-or-safety
    December 01, 2011 - JH ordered a urine pregnancy test, which came back positive.

  20. Right Regimen, Wrong Cancer: Patient Catches Medical Error | PSNet

    psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
    August 01, 2006 - clinicians decided to defer treatment, and failure to specify the blood counts and other laboratory test
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