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  1. In Conversation With… Lawrence Smith, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
    February 01, 2012 - Supervision in the outpatient clinic: effects on teaching and patient care.

  2. Amended Lab Results: Communication Slip | PSNet

    psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
    September 26, 2012 - Amended Lab Results: Communication Slip Citation Text: Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49791/psn-pdf
    April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable April 1, 2017 Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable The Case An 84-year-old wo…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33797/psn-pdf
    January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice January 1, 2016 Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…

  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
    January 01, 2020 - Spotlight Spotlight Inpatient Stroke Management in a Patient with Type 1 Diabetes and Home Insulin Pump Source and Credits • This presentation is based on the October 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Berit B…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49803/psn-pdf
    January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3 August 1, 2017 Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3 The Case A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the app…

  7. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
    May 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case May 2004 Too Tight Control: The Risks of Intensive Insulin Therapy Source and Credits This presentation is based on the May 2004 AHRQ WebM&M Spotlight Case in Medicine CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Comm…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49395/psn-pdf
    April 01, 2003 - Medication Overdose April 1, 2003 Kaushal R. Medication Overdose. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/medication-overdose The Case A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He was diagnosed with status epilepticus and started on a loading…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49700/psn-pdf
    February 01, 2014 - Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients February 1, 2014 Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes: Recognizing High-Risk Patients. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/nonsustaine…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33659/psn-pdf
    October 01, 2007 - Making Just Culture a Reality: One Organization's Approach October 1, 2007 Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach Perspective We've all been there...something goes wrong,…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73554/psn-pdf
    July 28, 2021 - EMS Patient Safety in the Field July 28, 2021 Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/ems-patient-safety-field Introduction Emergency medical services (EMS) personnel serve a critical role within the care continuum. They ar…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72837/psn-pdf
    September 01, 2022 - Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes. Originally published on March 11, 2021 Last updated on March 16, 2021 https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder- improves-maternal-and Summary Project…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33779/psn-pdf
    March 01, 2015 - Handoffs and Transitions January 22, 2014 Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/handoffs-and-transitions Annual Perspective 2014 Despite recent efforts to promote clinical integration, the United States health care system remains highly fragmented. From it…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36084/psn-pdf
    March 01, 2011 - Alarm algorithms in critical care monitoring. March 1, 2011 Imhoff M, Kuhls S. Alarm algorithms in critical care monitoring. Anesth Analg. 2006;102(5):1525-37. https://psnet.ahrq.gov/issue/alarm-algorithms-critical-care-monitoring The researchers discuss the ineffectiveness of current clinical monitoring systems an…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37235/psn-pdf
    March 04, 2015 - Radiologic errors and malpractice: a blurry distinction. March 4, 2015 Berlin L. Radiologic errors and malpractice: a blurry distinction. AJR Am J Roentgenol. 2007;189(3):517-22. https://psnet.ahrq.gov/issue/radiologic-errors-and-malpractice-blurry-distinction Reviewing legal and clinical literature, the author dis…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33999/psn-pdf
    March 07, 2005 - Center for Consumer Health Care Information Patient Safety Center. March 7, 2005 https://psnet.ahrq.gov/issue/center-consumer-health-care-information-patient-safety-center The Center's efforts for patient safety are highlighted, including New York's Patient Occurrence Reporting and Tracking System, Clinical Guidel…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40607/psn-pdf
    July 13, 2011 - Biomedical Complexity and Error. July 13, 2011 Patel VL, Kahol K, Buchman T, eds. J Biomed Inform. 2011;44:385-506.    https://psnet.ahrq.gov/issue/biomedical-complexity-and-error This special issue explores complexity in error management, clinical workflow, and decision making. https://psnet.ahrq.gov/is…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39205/psn-pdf
    January 06, 2010 - How Safe Is Your Hospital? January 6, 2010 Dr Foster Intelligence Unit. London, UK: Imperial College London; 2009. https://psnet.ahrq.gov/issue/how-safe-your-hospital This consumer-focused report ranked the 148 hospital trusts in the United Kingdom National Health Service (NHS) on patient safety, clinical effectiv…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33804/psn-pdf
    March 03, 2016 - In Conversation With… Paul McGann, MD March 1, 2016 In Conversation With… Paul McGann, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for Medicare & Medicaid Services (CMS). He…

  20. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care | PSNet

    psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
    June 28, 2023 - SPOTLIGHT CASE A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care Citation Text: Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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