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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33561/psn-pdf
    September 15, 2024 - Never Events September 15, 2024 Never Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/never-events PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in 2024. Backg…
  2. psnet.ahrq.gov/periodic-issue/periodic-issue-312
    October 27, 2021 - October 6, 2021 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, reports…
  3. psnet.ahrq.gov/periodic-issue/periodic-issue-339
    April 27, 2022 - April 27, 2022 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, reports,…
  4. psnet.ahrq.gov/periodic-issue/periodic-issue-430
    March 27, 2024 - March 6, 2024 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, reports, …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49771/psn-pdf
    July 01, 2016 - Unintended Consequences of CPOE October 1, 2016 Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe Case Objectives Explain how technology, including computerized provider order entry, can transform, rather than eliminate, hazards. Recogni…
  6. psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
    July 01, 2012 - EMR Entry Error: Not So Benign Citation Text: Koppel R. EMR Entry Error: Not So Benign. 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 Endno…
  7. psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
    February 26, 2025 - In Conversation With… Shantanu Agrawal, MD, MPhil September 1, 2019  Citation Text: In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Co…
  8. psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Andrew P.J. …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49735/psn-pdf
    June 01, 2015 - Anchoring Bias With Critical Implications June 1, 2015 Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications Case Objectives Appreciate that diagnostic errors are common in primary and ambulatory care. Define premature clo…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49618/psn-pdf
    February 01, 2011 - One Toxic Drug Is Not Like Another February 1, 2011 Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/one-toxic-drug-not-another Case Objectives Distinguish between the three distinct regulatory processes of board certification, medical licensure, and credential…
  11. psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
    March 24, 2025 - In Conversation With… Rebecca Lawton, PhD September 1, 2018  Citation Text: In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837660/psn-pdf
    July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse Outcomes July 8, 2022 Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes The Cases Case 1: A 64-year-old man came in for a routine bron…
  13. psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
    October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 12, 2020 …
  14. psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
    February 01, 2023 - SPOTLIGHT CASE When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Citation Text: Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33764/psn-pdf
    April 01, 2014 - In Conversation With… Tejal K. Gandhi, MD, MPH April 1, 2014 In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph Editor's note: Tejal K. Gandhi, MD, MPH, CPPS, is an Associate Professor of Medicine at Harvard Medical School …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33784/psn-pdf
    April 01, 2015 - In Conversation With… David Urbach, MD, MSc April 1, 2015 In Conversation With… David Urbach, MD, MSc. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc Editor's note: Dr. David Urbach is Professor of Surgery and Health Policy, Management, and Evaluation at the University…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33770/psn-pdf
    August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH August 1, 2014 In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of California, S…
  18. psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
    August 21, 2015 - SPOTLIGHT CASE Order Interrupted by Text: Multitasking Mishap Citation Text: Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49807/psn-pdf
    October 01, 2017 - Translating From Normal to Abnormal October 1, 2017 Turner AM. Translating From Normal to Abnormal. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/translating-normal-abnormal Case Objectives Define limited English proficiency. Understand the principal approaches to machine translation. Review the way mach…
  20. psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
    September 01, 2017 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks Citation Text: Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. …

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