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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. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49686/psn-pdf
    May 01, 2013 - Don't Use That Port: Insert a PICC May 1, 2013 Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc The Case A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with fever and abdominal pain. A comp…
  3. 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…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33880/psn-pdf
    May 01, 2019 - Safety in the Prehospital Emergency Medical Services Setting May 1, 2019 Patterson DP, Yealy DM. Safety in the Prehospital Emergency Medical Services Setting. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting Perspective Emergency medical services (E…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49616/psn-pdf
    December 01, 2010 - Milliliters vs. Milligrams December 1, 2010 Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams The Case   A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His evaluation showed acu…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49756/psn-pdf
    April 01, 2016 - Lost in Sign Out and Documentation April 1, 2016 Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation The Case A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the emergency physician, …
  7. psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
    January 01, 2018 - In Conversation With… Robert Hirschtick, MD January 1, 2018  Also Read an Essay Citation Text: In Conversation With… Robert Hirschtick, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60744/psn-pdf
    July 29, 2020 - The NSTEMI Curbside Consultation July 29, 2020 Villablanca AC, Wong GX. The NSTEMI Curbside Consultation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/nstemi-curbside-consultation Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical E…
  9. psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd
    July 10, 2024 - Patient Safety Initiatives July 10, 2024 Using the ecological systems theory to understand
  10. 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…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49718/psn-pdf
    January 01, 2015 - Too Much, Too Fast September 1, 2014 Tuot D. Too Much, Too Fast. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/too-much-too-fast The Case A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for fever, tachycardia, and increased respiratory secretions. H…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49493/psn-pdf
    November 01, 2005 - Infused, Not Ingested November 1, 2005 Foley M. Infused, Not Ingested. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/infused-not-ingested The Case A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering contrast, an unfamiliar task for this particular nurse. Rathe…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49526/psn-pdf
    December 01, 2006 - Crossing the Borderline December 1, 2006 Oldham JM. Crossing the Borderline. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/crossing-borderline The Case A 24-year-old woman with borderline personality disorder was admitted to an inpatient psychiatry unit following a failed suicide attempt with excess doses…
  14. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
    October 01, 2013 - PowerPoint Presentation Spotlight Case It's Sarah, not Stephen! 1 This presentation is based on the October 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Urmimala Sarkar, MD, MPH, University of California at San Francisco Editor, AHRQ WebM&…
  15. psnet.ahrq.gov/web-mm/transition-nowhere
    March 21, 2009 - Transition to Nowhere Citation Text: Farrell TW. Transition to Nowhere. 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 Endnote tagged PubMed…
  16. psnet.ahrq.gov/web-mm/too-hot-comfort
    May 19, 2015 - Too Hot For Comfort Citation Text: Cleland H, Wasiak J. Too Hot For Comfort. 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 P…
  17. 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…
  18. psnet.ahrq.gov/web-mm/surprise-wire
    July 15, 2020 - Surprise Wire Citation Text: Pearl JM, Donaldson NE. Surprise Wire. 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 PubMedId R…
  19. psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
    May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap Citation Text: Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Forma…
  20. psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
    November 10, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Errors Case Studies  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Maria Mirica, PRIDE Group …

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