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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - As a result, a
multidisciplinary team began researching approaches for reducing medical errors during
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - Multiple
approaches are necessary to get closer to concepts that we're trying to measure.
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psnet.ahrq.gov/issue/understanding-and-improving-everyday-work-healthcare
May 13, 2020 - International Meeting/Conference
Understanding and Improving Everyday Work in Healthcare.
Citation Text:
Clinical Human Factors Group. May 16, 2023, 9:00 AM--12:30 PM (eastern).
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psnet.ahrq.gov/issue/key-cpoe
May 21, 2008 - Newspaper/Magazine Article
The key to CPOE.
Citation Text:
Ross C, Banchy P. The key to CPOE. Health management technology. 2007;28(11):22, 24.
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psnet.ahrq.gov/issue/annual-diagnostic-excellence-summit
May 09, 2024 - United States Meeting/Conference
Annual Diagnostic Excellence Summit.
Citation Text:
The Armstrong Institute Center for Diagnostic Excellence. Johns Hopkins University, Baltimore, MD, May 22, 2024, 9:00 AM-4:00 PM (eastern).
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psnet.ahrq.gov/issue/isqua-2013-edinburgh-recorded-sessions
November 02, 2011 - Audiovisual Presentation
ISQua 2013: Edinburgh Recorded Sessions.
Citation Text:
ISQua; International Society for Quality in Health Care.
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Danger in Disruption
October 1, 2009
Fontaine DK. Danger in Disruption. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had
metabolic alkalosis (pH = 7.58), and her last peripheral…
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psnet.ahrq.gov/node/33772/psn-pdf
September 01, 2014 - In Conversation With… Rosemary Gibson, MSc
September 1, 2014
In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
Editor's note: Rosemary Gibson, MSc, is Senior Advisor to The Hastings Center and an editor for JAMA
Internal Medicin…
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psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room
– Mixing Up the Ampules
January 29, 2021
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
The Case
A…
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psnet.ahrq.gov/node/49673/psn-pdf
December 01, 2012 - A Real Heartache
December 1, 2012
Polevoi SK. A Real Heartache. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/real-heartache
The Case
A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The
pain began at rest, and it radiated to his back and left axilla. He had…
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psnet.ahrq.gov/node/33685/psn-pdf
May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA
May 1, 2009
In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and
Family M…
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psnet.ahrq.gov/node/49835/psn-pdf
January 01, 2020 - Don't Pick the PICC
July 1, 2018
McGill RL. Don't Pick the PICC. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/dont-pick-picc
The Case
A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy;
glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
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psnet.ahrq.gov/node/33665/psn-pdf
March 01, 2008 - Creation of a Medical Procedure Service to Improve
Patient Safety
March 1, 2008
Smith CC, CHuang G. Creation of a Medical Procedure Service to Improve Patient Safety. PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
Perspective
Introduction and …
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psnet.ahrq.gov/node/33639/psn-pdf
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Where did your interest in safety come from?
Dr. James Bagian: I don't know …
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psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx
Spotlight
Premature Closure: Was it Just Syncope?
Source and Credits
• This presentation is based on the November 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit i…
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - A Seasonal Care Transition Failure
July 1, 2011
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
The Case
A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine
resident—for routine follow-up…
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psnet.ahrq.gov/node/33682/psn-pdf
April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH
April 1, 2009
In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
Editor's note: Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent
s…
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psnet.ahrq.gov/node/49518/psn-pdf
August 01, 2006 - It's All in the Syringe
August 1, 2006
Weingart SN. It's All in the Syringe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/its-all-syringe
The Case
A 33-year-old man with type 2 diabetes presented to his physician's office to discuss his diabetes
management. The patient admitted not taking his medications…
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psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
October 01, 2003 - Hospital Admission Due to High-Dose Methotrexate Drug Interaction
Citation Text:
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. 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/are-two-insulin-pumps-better-one
March 01, 2005 - Are Two Insulin Pumps Better Than One?
Citation Text:
Cook CB. Are Two Insulin Pumps Better Than One?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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