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psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
June 01, 2005 - In response to “Getting to the Root of the Matter” (June 2005)
September 1, 2005
View more articles from the same authors.
Citation Text:
Grondin L, Saint S, Flanders S, et al. In response to “Getting to the Root of the Matter” (June 2005). PSNet [internet]. Rockv…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
May 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer?
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Source and Credits
This presentation is based on the May 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sidney W.A. Dekker, Ph…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
October 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case October 2004
Thin Air
Source and Credits
This presentation is based on the Oct. 2004
AHRQ WebM&M Spotlight Case in Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: David M. Gaba, MD, Stanford Univer…
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psnet.ahrq.gov/
March 25, 2025 - This website is up to date as of March 24, 2025. You will not be able to register for an account and will no longer be able to obtain Continuing Medical Education (CME), Maintenance of Certification (MOC), or Continuing Pharmacy Education (CPE) credits. We are not taking submissions for WebM&M cases, Innovations, Train…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.197_slideshow.ppt
April 01, 2009 - Spotlight Case July 2008
Spotlight Case
Breakage of a PICC Line
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Source and Credits
This presentation is based on the April 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Vesselin Dimov, MD
Creighton University
Editor, AHRQ WebM&M: …
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - Sarah Mossburg: Thinking about embedding systems approaches, how does that come together with national … Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment).
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psnet.ahrq.gov/perspective/measuring-patient-safety
December 14, 2022 - Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). … Sarah Mossburg: Thinking about embedding systems approaches, how does that come together with national
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - If the previous two approaches fail, and a member of a care team continues to fail to follow the care
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - Stewardship Initiative Resources
Despite these challenges, there are effective stewardship approaches
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - Ensuring Patient and Workforce Safety Culture in
Healthcare
March 27, 2024
Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
Introduction
In 2020, the I…
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psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
September 13, 2023 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use
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March 31…
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - SPOTLIGHT CASE
Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough
Citation Text:
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
August 01, 2010 - In Conversation with...Richard P. Shannon, MD
August 1, 2010
Also Read an Essay
Citation Text:
In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010.In Conversation with...Richard P. Shannon, MD. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - 1.2% reduction in nonparticipating hospitals, demonstrating the value of quality and safety efforts. 6 Approaches
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psnet.ahrq.gov/node/866578/psn-pdf
August 28, 2024 - and other dosing errors
contribute to racial and ethnic disparities in pediatric patient safety.11
Approaches
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psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
September 09, 2013 - Specific prophylactic approaches to reduce immunosuppression-related adverse effects include treatments
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - Understand the alternative approaches to emergency radiology coverage, including teleradiology.
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - List approaches to enhance closed-loop communication between remote telemetry monitoring staff
and bedside
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psnet.ahrq.gov/node/33885/psn-pdf
August 01, 2019 - For the overall problem of in-basket work, there are several different approaches.