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psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
April 01, 2005 - Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet)
Robert M. Wachter, MD | April 1, 2005
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Citation Text:
Wachter R. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Ne…
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psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
April 01, 2005 - In Conversation with…Christopher P. Landrigan, MD
April 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk
Citation Text:
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quali…
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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - Hypoxic Gas Supply from Cross-Connected Pipelines
Citation Text:
Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - Importance of Following Safe Practices for Infant Feeding
and Handling Expressed Breast Milk
December 18, 2024
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling
Expressed Breast Milk. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/importance-following-saf…
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psnet.ahrq.gov/node/33726/psn-pdf
March 01, 2012 - In Conversation With… Richard C. Boothman, JD
March 1, 2012
In Conversation With… Richard C. Boothman, JD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
Editor's note: Rick Boothman, an attorney, is the chief risk officer for the University of Michigan Health
System…
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - In Conversation with Timothy Vogus about High
Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization
(HRO) Principles and Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/persp…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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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…
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psnet.ahrq.gov/node/33791/psn-pdf
September 01, 2015 - In Conversation With… Vineet Arora, MD, MAPP
September 1, 2015
In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
Editor's note: Vineet Arora, MD, MAPP, is Director of GME Clinical Learning Environment Innovation,
Associate Pr…
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psnet.ahrq.gov/node/838197/psn-pdf
September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a
Plan.
September 28, 2022
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022.
https://psnet.…
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psnet.ahrq.gov/node/33857/psn-pdf
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
Editor's note: Dr. Blumenthal is President of the Commonwealth Fund and served as the National
Coordinator …
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psnet.ahrq.gov/node/836877/psn-pdf
May 16, 2022 - Some areas are probably common to other settings
too, like medication errors, particularly with children
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psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
January 01, 2008 - individual hospitals have presented their experiences and outcomes from their work in a variety of areas
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - clearly unsafe practice should be permitted, and it is much more reasonable to assert, as we do in other areas
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - A Postpartum Woman with an Erroneous SARS-CoV-2
Test
April 28, 2021
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
The Case
A full-term pregnant patient was admitted in March 2…
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - WebM&M: Case Studies
WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - SPOTLIGHT CASE
Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation
Citation Text:
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety
Brian K. Alldredge, PharmD; Mary Anne Koda-Kimble, PharmD | April 1, 2006
Also Read a Conversation
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Citation Text:
Alldredge BK, Koda-Kimb…
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
Citation Text:
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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