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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - analysis involves identifying functions, describing the performance variability of these functions, analyzing
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psnet.ahrq.gov/node/851568/psn-pdf
July 31, 2023 - clinical decision
support (CDS) can help identify patients at high risk of clinical deterioration by analyzing
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psnet.ahrq.gov/perspective/application-safety-ii-principles
August 28, 2024 - analysis involves identifying functions, describing the performance variability of these functions, analyzing
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psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
June 14, 2023 - clinical decision support (CDS) can help identify patients at high risk of clinical deterioration by analyzing
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psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis
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psnet.ahrq.gov/node/33622/psn-pdf
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare
I…
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/web-mm/hard-swallow
April 26, 2023 - Hard to Swallow
Citation Text:
Driver J. Hard to Swallow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/web-mm/liposuction-gone-awry
July 01, 2003 - Liposuction Gone Awry
Citation Text:
Yates JA. Liposuction Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/49612/psn-pdf
November 01, 2010 - Treatment Challenges After Discharge
November 1, 2010
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
Case Objectives
Understand types and frequencies of adverse events occurring between patient discharge from the
hospital …
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - Breakage of a PICC Line
April 1, 2009
Dimov V. Breakage of a PICC Line. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/breakage-picc-line
Case Objectives
Appreciate the incidence and consequences of PICC line breakage.
Understand the risk factors for PICC line breakage.
Understand the treatment options in…
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psnet.ahrq.gov/node/33864/psn-pdf
January 01, 2019 - How Does Health Care Simulation Affect Patient Care?
August 1, 2018
Lopreiato JO. How Does Health Care Simulation Affect Patient Care? PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
Perspective
Introduction
Health care simulation programs have spread…
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - Patient Safety Indicators
Citation Text:
Tokareva I, Romano P. Patient Safety Indicators.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - Annual Perspective
Updates in the Role of Health IT in Patient Safety
February 21, 2020
View more articles from the same authors.
Citation Text:
Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. Rockville …
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - Patient Safety Indicators
April 26, 2023
Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/patient-safety-indicators
Background
Over the past 25 years, policymakers and providers, payers, and purchasers of health care have
increasingly focused attention on pati…
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Fatal Twist in Pseudohyperkalemia
1
Source and Credits
This presentation is based on the August 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Le…
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Mother's Milk, but Whose Mother?
Citation Text:
Dougherty D. Mother's Milk, but Whose Mother?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/breakage-picc-line
June 21, 2023 - SPOTLIGHT CASE
Breakage of a PICC Line
Citation Text:
Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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