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  1. psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
    July 23, 2024 - Suicide Prevention in an Emergency Department Population: ED-SAFE Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL April 24, 2024 View more articles from the same authors. Innovation …
  2. psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
    September 01, 2004 - SPOTLIGHT CASE Unintended Consequences of CPOE Citation Text: Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNot…
  3. psnet.ahrq.gov/web-mm/another-fall
    June 01, 2010 - SPOTLIGHT CASE Another Fall Citation Text: Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867357/psn-pdf
    December 18, 2024 - Hypoxemia after Emergency Intubation December 18, 2024 Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation The Case A 19-month-old child was brought to the emergency department (ED) via ambulance after drowning in a p…
  5. psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
    August 31, 2022 - SPOTLIGHT CASE Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. Citation Text: Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866618/psn-pdf
    December 31, 2024 - A Fatal Twist in Pseudohyperkalemia December 31, 2024 Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for C…
  7. psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
    June 01, 2003 - SPOTLIGHT CASE Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care Citation Text: Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
  8. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…
  9. psnet.ahrq.gov/issue/nurses-role-patient-safety
    June 09, 2011 - Commentary Nurses' role in patient safety. Citation Text: Hughes RG, Clancy CM. Nurses' role in patient safety. J Nurs Care Qual. 2009;24(1):1-4. doi:10.1097/NCQ.0b013e31818f55c7. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
  10. psnet.ahrq.gov/issue/systematic-review-incidence-and-characteristics-preventable-adverse-drug-events-ambulatory
    July 15, 2010 - Review Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Citation Text: Thomsen LA, Winterstein AG, S⊘ndergaard B, et al. Systematic Review of the Incidence and Characteristics of Preventable Adverse Drug Events in Ambulatory …
  11. psnet.ahrq.gov/issue/nursing-student-errors-and-near-misses-three-years-data
    October 20, 2021 - Study Nursing student errors and near misses: three years of data. Citation Text: Silvestre JH, Spector ND. Nursing student errors and near misses: three years of data. J Nurs Educ. 2023;62(1):12-19. doi:10.3928/01484834-20221109-05. Copy Citation Format: DOI Google Scholar…
  12. psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
    April 26, 2023 - Our role is to analyze data related to patient safety, especially monitoring of general care patients
  13. psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-acute-hospital-care-units
    April 26, 2023 - Our role is to analyze data related to patient safety, especially monitoring of general care patients
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72517/psn-pdf
    November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. November 25, 2020 Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49483/psn-pdf
    June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…
  16. psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
    February 26, 2025 - In Conversation With… Leah Binder, MA, MGA April 1, 2014  Citation Text: In Conversation With… Leah Binder, MA, MGA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Fo…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72516/psn-pdf
    November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
  18. psnet.ahrq.gov/issue/ambulance-stretcher-adverse-events
    March 23, 2011 - Study Ambulance stretcher adverse events. Citation Text: Wang HE, Weaver MD, Abo BN, et al. Ambulance stretcher adverse events. Qual Saf Health Care. 2009;18(3):213-216. doi:10.1136/qshc.2007.024562. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
  19. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
    September 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case September 2004 Poor Prognosis? Source and Credits This presentation is based on the September 2004 AHRQ WebM&M Spotlight Case in Surgery See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Elizabeth B. Lamont, M…
  20. psnet.ahrq.gov/issue/complication-rates-weekends-and-weekdays-us-hospitals
    August 31, 2011 - Study Complication rates on weekends and weekdays in US hospitals. Citation Text: Bendavid E, Kaganova Y, Needleman J, et al. Complication rates on weekends and weekdays in US hospitals. Am J Med. 2007;120(5):422-8. Copy Citation Format: Google Scholar PubMed BibTeX EndNo…

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