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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.227_slideshow.ppt
    November 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Treatment Challenges After Discharge * * Source and Credits This presentation is based on the November 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Chase Coffey, MD, Henry Ford Health System,…
  2. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.290_slideshow.ppt
    February 01, 2013 - Spotlight Case July 2008 Spotlight Case Delay in Treatment: Failure to Contact Patient Leads to Significant Complications * * Source and Credits This presentation is based on the February 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49418/psn-pdf
    October 01, 2003 - Charcoal Lavage of the Lungs October 1, 2003 Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/charcoal-lavage-lungs The Case A 47-year-old man presented to an emergency department (ED) with altered mental status, and was believed to have a probable overdose. He receiv…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72616/psn-pdf
    December 22, 2020 - Adverse Events in Dentistry December 22, 2020 Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/adverse-events-dentistry Introduction Similar to many other healthcare settings, dentistry carries with it inherent patient safety risks. D…
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
    April 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Bad Writing, Wrong Medication * * Source and Credits This presentation is based on the April 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Beth Devine, PharmD, MBA, PhD University of Washingto…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33777/psn-pdf
    January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care January 1, 2015 Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33798/psn-pdf
    January 01, 2015 - Accountability in Patient Safety January 1, 2015 Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/accountability-patient-safety Annual Perspective 2015 The tension between the no-blame culture espoused in the early years of the safety movement and …
  8. psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
    September 09, 2013 - SPOTLIGHT CASE Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care Citation Text: Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
  9. psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
    September 01, 2016 - SPOTLIGHT CASE Multifactorial Medication Mishap Citation Text: Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNot…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846564/psn-pdf
    March 29, 2023 - Technology as a Tool for Improving Patient Safety March 29, 2023 Holmgren AJ, McBride S, Gale B, et al. Technology as a Tool for Improving Patient Safety . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety Introduction  In the past several decades, technological a…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74121/psn-pdf
    November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. November 30, 2021 Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…
  12. psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
    November 13, 2024 - Delayed Diagnosis of Endocrinologic Emergencies Citation Text: Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33833/psn-pdf
    May 01, 2017 - In Conversation With… David Juurlink, MD, PhD May 1, 2017 In Conversation With… David Juurlink, MD, PhD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd Editor's note: Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of Toronto, w…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33878/psn-pdf
    April 01, 2019 - In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD April 1, 2019 In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd Editor's note: Dr. Schulz Moore is the Director of Learning and Teaching at…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49750/psn-pdf
    January 01, 2016 - A Room Without Orders January 1, 2016 Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/room-without-orders Case Objectives Review a common process for planned direct hospital admissions. Describe challenges of prioritizing day-to-day patient care activities wi…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49737/psn-pdf
    June 01, 2015 - Unseen Perils of Urinary Catheters June 1, 2015 Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters The Case A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
  17. psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
    July 21, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Safety Improvement  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNe…
  18. psnet.ahrq.gov/print/pdf/node/854855
    January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Patient as a Team Member in Clinical Care Curated Library Foundations Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving Patient Safety. Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, F…
  19. psnet.ahrq.gov/print/pdf/node/838351
    July 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Diagnostic Safety Improvement Curated Library Foundations Improving Diagnosis in Health Care. Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73553/psn-pdf
    July 28, 2021 - In Conversation With... James Augustine, MD July 28, 2021 In Conversation With.. James Augustine, MD. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-james-augustine-md Editor’s Note: James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he p…

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