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5221. Multifactorial Medication Mishap | PSNet
      psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
      September 01, 2016 - SPOTLIGHT CASE Multifactorial Medication Mishap Citation Text: Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNot…

5222. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications | PSNet
      psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
      February 01, 2004 - SPOTLIGHT CASE Delay in Treatment: Failure to Contact Patient Leads to Significant Complications Citation Text: Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…

5223. In Conversation With… David Urbach, MD, MSc | PSNet
      psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
      June 12, 2019 - In Conversation With… David Urbach, MD, MSc April 1, 2015  Citation Text: In Conversation With… David Urbach, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation …

5224. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33793/psn-pdf
      November 01, 2015 - In Conversation With… Kaveh Shojania, MD November 1, 2015 In Conversation With… Kaveh Shojania, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md Editor's note: Kaveh Shojania, MD, is Editor-in-Chief of BMJ Quality and Safety and Director of the Centre for Quality Impro…

5225. Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx (pdf file)
      psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
      January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx Spotlight Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/…

5226. The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation | PSNet
      psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
      April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL August 30, 2023 View more articles from the…

5227. Classics and Emerging Classics | PSNet
      psnet.ahrq.gov/classics
      August 01, 2023 - Classics and Emerging Classics To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient sa…

5228. The Wet Read | PSNet
      psnet.ahrq.gov/web-mm/wet-read
      October 01, 2017 - SPOTLIGHT CASE The Wet Read Citation Text: Arenson RL. The Wet Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

5229. Postdischarge Follow-Up Phone Call | PSNet
      psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
      May 19, 2021 - SPOTLIGHT CASE Postdischarge Follow-Up Phone Call Citation Text: Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Schol…

5230. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet
      psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
      September 30, 2020 - SPOTLIGHT CASE Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Citation Text: Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…

5231. WebM&M: Case Studies | PSNet
      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…

5232. In Conversation With… Sigall K. Bell, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
      February 26, 2025 - In Conversation With… Sigall K. Bell, MD September 1, 2018  Citation Text: In Conversation With… Sigall K. Bell, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Fo…

5233. In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
      November 27, 2023 - that safety competencies are an explicit part of the curriculum for the clinical rotation and clearly communicating

5234. The Role of Undergraduate Nursing Education in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
      November 27, 2023 - that safety competencies are an explicit part of the curriculum for the clinical rotation and clearly communicating

5235. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. | PSNet
      psnet.ahrq.gov/issue/factors-associated-mental-health-outcomes-among-health-care-workers-exposed-coronavirus
      March 24, 2019 - Study Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. Citation Text: Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 20…

5236. How effective are patient safety initiatives? A retrospective patient record review study of changes to patient safety over time. | PSNet
      psnet.ahrq.gov/issue/how-effective-are-patient-safety-initiatives-retrospective-patient-record-review-study
      March 18, 2013 - Study Classic How effective are patient safety initiatives? A retrospective patient record review study of changes to patient safety over time. Citation Text: Baines RJ, Langelaan M, de Bruijne M, et al. How effective are patient safety initiatives? A retrospect…

5237. Leapfrog Hospital Safety Score, Magnet designation, and healthcare-associated infections in United States hospitals. | PSNet
      psnet.ahrq.gov/issue/leapfrog-hospital-safety-score-magnet-designation-and-healthcare-associated-infections-united
      July 27, 2022 - Study Leapfrog Hospital Safety Score, Magnet designation, and healthcare-associated infections in United States hospitals. Citation Text: Pakyz AL, Wang H, Ozcan YA, et al. Leapfrog Hospital Safety Score, Magnet Designation, and Healthcare-Associated Infections in United States Hospitals…

5238. Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial. | PSNet
      psnet.ahrq.gov/issue/interdisciplinary-collaboration-across-secondary-and-primary-care-improve-medication-safety
      December 21, 2022 - Study Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial. Citation Text: Johansen JS, Halvorsen KH, Svendsen K, et al. Interdisciplinary collaboration across secondary and prima…

5239. Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. | PSNet
      psnet.ahrq.gov/issue/primary-care-relevant-interventions-prevent-falling-older-adults-systematic-evidence-review
      May 27, 2020 - Review Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Citation Text: Michael YL, Whitlock EP, Lin JS, et al. Primary care-relevant interventions to prevent falling in older adults: a syst…

5240. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. | PSNet
      psnet.ahrq.gov/issue/association-icu-or-hospital-admission-unintentional-discontinuation-medications-chronic
      November 06, 2015 - Study Classic Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. Citation Text: Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of me…