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  1. psnet.ahrq.gov/web-mm/near-miss-neonate
    August 15, 2018 - Near Miss With Neonate Citation Text: Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
  2. psnet.ahrq.gov/issue/ashp-ppag-guidelines-providing-pediatric-pharmacy-services-hospitals-and-health-systems
    April 24, 2018 - Commentary ASHP–PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems. Citation Text: Eiland LS, Benner K, Gumpper KF, et al. ASHP-PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems. J Pediatr Pharmacol Ther. 2018…
  3. psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx Spotlight Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849661/psn-pdf
    June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery June 28, 2023 Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023. https://psnet.ahrq.gov/web…
  5. psnet.ahrq.gov/issue/bundaberg-and-beyond-duty-disclose-adverse-events-patients
    January 12, 2022 - Commentary Bundaberg and beyond: duty to disclose adverse events to patients. Citation Text: Madden B, Cockburn T. Bundaberg and beyond: duty to disclose adverse events to patients. J Law Med. 2007;14(4):501-27. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X…
  6. psnet.ahrq.gov/web-mm/beeline-spine
    March 01, 2014 - SPOTLIGHT CASE Beeline to Spine Citation Text: Smetana GW. Beeline to Spine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
  7. psnet.ahrq.gov/issue/breaking-rules-understanding-non-compliance-policies-and-guidelines
    September 24, 2018 - Commentary Breaking the rules: understanding non-compliance with policies and guidelines. Citation Text: Carthey J, Walker S, Deelchand V, et al. Breaking the rules: understanding non-compliance with policies and guidelines. BMJ. 2011;343:d5283. doi:10.1136/bmj.d5283. Copy Citation …
  8. psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice
    February 02, 2022 - Review Medicines safety in anaesthetic practice. Citation Text: Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157. doi:10.1016/j.bjae.2019.01.001. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
  9. psnet.ahrq.gov/issue/development-and-evaluation-i-pass-picu-standard-electronic-template-improve-referral
    June 14, 2023 - Study Development and evaluation of I-PASS-to-PICU: a standard electronic template to improve referral communication for inter-facility transfers to the pediatric intensive care unit. Citation Text: Parikh NR, Francisco LS, Balikai SC, et al. Development and evaluation of I-PASS-to-PICU:…
  10. psnet.ahrq.gov/issue/safety-and-communication-operating-room-safety-questionnaire-after-implementation-blood-borne
    September 23, 2020 - Study Safety and communication in the operating room: a safety questionnaire after the implementation of a blood-borne pathogen exposure checkpoint in the surgical safety checklist preprocedure time-out. Citation Text: Kane P, Marley R, Daney B, et al. Safety and Communication in the Ope…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49611/psn-pdf
    October 01, 2010 - Clinical Practice Guideline Number 5: Depression in Primary Care, Volume 2: Treatment of Major Depression
  12. psnet.ahrq.gov/issue/consensus-statement-effective-communication-urgent-diagnoses-and-significant-unexpected
    November 16, 2022 - Organizational Policy/Guidelines Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. Cit…
  13. psnet.ahrq.gov/issue/medicine-wandering-mind-mind-wandering-medical-practice
    August 28, 2017 - Review Medicine for the wandering mind: mind wandering in medical practice. Citation Text: Smallwood J, Mrazek MD, Schooler JW. Medicine for the wandering mind: mind wandering in medical practice. Med Educ. 2011;45(11):1072-80. doi:10.1111/j.1365-2923.2011.04074.x. Copy Citation …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60007/psn-pdf
    March 04, 2020 - ISMP Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. March 4, 2020 Horsham, PA: Institute for Safe Medication Practices; 2020. https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-implementation-and-use-smart-infusion- pumps Smart pumps are widely available as a medicat…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46831/psn-pdf
    April 18, 2018 - Guideline Summary: Medication Safety. April 18, 2018 Guideline Summary: Medication Safety. AORN J. 2018;107(4):489-494. doi:10.1002/aorn.12096. https://psnet.ahrq.gov/issue/guideline-summary-medication-safety Perioperative medication errors can result in patient harm as well as emotional distress among clinical te…
  16. psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error
    April 14, 2011 - Review Emerging Classic Hierarchy and medical error: speaking up when witnessing an error. Citation Text: Peadon R (R), Hurley J, Hutchinson M. Hierarchy and medical error: speaking up when witnessing an error. Safety Sci. 2020;125:104648. doi:10.1016/j.ssci.202…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49737/psn-pdf
    June 01, 2015 - Unseen Perils of Urinary Catheters June 1, 2015 Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters The Case A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49852/psn-pdf
    February 01, 2019 - Triaging Interhospital Transfers February 1, 2019 Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/triaging-interhospital-transfers Case Objectives Recognize that transfer of patients between acute care hospitals is common. Realize that the interhospital transfer…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49850/psn-pdf
    January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia January 1, 2019 Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia The Case A 72-year-old woman with a history of severe peripheral vascular dis…
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
    December 01, 2013 - PowerPoint Presentation Spotlight Case New Oral Anticoagulants 1 This presentation is based on the December 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Margaret C. Fang, MD, MPH, University of California, San Francisco Editor, AHRQ WebM&M…

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