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  1. psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
    September 01, 2015 - Good Night's Sleep Gone Wrong Citation Text: Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. 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…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861882/psn-pdf
    January 31, 2024 - Patient Safety in Office-Based Care Settings January 31, 2024 Ricciardi R, Lee M, Mossburg S. Patient Safety in Office-Based Care Settings. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings The Institute of Medicine’s 2000 publication To Err Is Human summarized res…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50756/psn-pdf
    December 18, 2019 - A Mistaken Dose of Naloxone? December 18, 2019 Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone The Case A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up appointment. He h…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49399/psn-pdf
    May 01, 2003 - Ectopic or Not? May 1, 2003 Givens VM, Lipscomb GH. Ectopic or Not? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/ectopic-or-not The Case The patient is a 24-year-old woman, gravida 4, para 1, ectopic 1, at 6 weeks from her last menstrual period. She presents to the emergency department with a 3-day histo…
  5. psnet.ahrq.gov/web-mm/surgical-personality-threat-patient-safety
    February 24, 2021 - SPOTLIGHT CASE Is the "Surgical Personality" a Threat to Patient Safety? Citation Text: Bosk CL. Is the "Surgical Personality" a Threat to Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citati…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33731/psn-pdf
    June 01, 2012 - An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up June 1, 2012 Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom Perspecti…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73229/psn-pdf
    May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities May 26, 2021 Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
  8. psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
    November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012  View more articles from the same authors. Citation Text: Joseph A, Malone EB. The Physical Environment: An Often Unc…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49432/psn-pdf
    February 09, 2004 - Delay in Initiating Antibiotics Results in Fatal Error February 1, 2004 Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error Case Objectives Understand the importance of ongoing patient re-evaluati…
  10. psnet.ahrq.gov/web-mm/crossing-borderline
    June 01, 2022 - Crossing the Borderline Citation Text: Oldham JM. Crossing the Borderline. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33722/psn-pdf
    December 01, 2011 - In Conversation With… Ann L. Hendrich, RN, PhD December 1, 2011 In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd Editor's note: Ann L. Hendrich, RN, PhD, is Vice President of Clinical Excellence Operations and Executive Di…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33670/psn-pdf
    July 01, 2008 - In Conversation with...Albert Wu, MD, MPH July 1, 2008 In Conversation with..Albert Wu, MD, MPH. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph Editor's note: Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins School of Public Health…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49613/psn-pdf
    November 01, 2010 - Mother's Milk, but Whose Mother? November 1, 2010 Dougherty D. Mother's Milk, but Whose Mother? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/mothers-milk-whose-mother The Case A 2-month-old otherwise healthy infant was admitted to the hospital to rule out sepsis. The infant had been exclusively breastfed…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49426/psn-pdf
    November 01, 2003 - Don't Push November 1, 2003 Meltzer HY. Don't Push. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dont-push The Case A 37-year-old HIV-positive woman was brought to the emergency room by her family because she had exhibited altered mentation for 3 days. The patient had been diagnosed with HIV infection 3 …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49856/psn-pdf
    March 01, 2019 - Premature Extubation March 1, 2019 Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/premature-extubation The Case A 73-year-old woman with a history of carotid artery stenosis was admitted for an elective carotid endarterectomy. The procedure was initially thought to …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49809/psn-pdf
    October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy October 1, 2017 Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy The Case A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…
  17. psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-home-residents
    July 23, 2024 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 28, 2021 Innovation Contact …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33721/psn-pdf
    November 01, 2011 - Lesson from the VA's Team Training Program November 1, 2011 Neily J, Mills PD, Paull DE, et al. Lesson from the VA's Team Training Program . PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/lesson-vas-team-training-program Perspective Introduction The Veterans Health Administration (VHA) National Center…
  19. psnet.ahrq.gov/web-mm/one-dose-fifty-pills
    January 13, 2021 - One Dose, Fifty Pills Citation Text: Smith L. One Dose, Fifty Pills . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49489/psn-pdf
    September 01, 2005 - Double Trouble September 1, 2005 Gurwitz JH. Double Trouble. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/double-trouble Case Objectives Appreciate the incidence of adverse drug events in older persons List preventative measures that can be used to minimize medication errors in this population Encourage…

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