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psnet.ahrq.gov/primer/opioid-safety
December 15, 2024 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
March 15, 2025 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/node/73103/psn-pdf
March 31, 2021 - The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.197_slideshow.ppt
April 01, 2009 - Spotlight Case July 2008
Spotlight Case
Breakage of a PICC Line
*
*
Source and Credits
This presentation is based on the April 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Vesselin Dimov, MD
Creighton University
Editor, AHRQ WebM&M: …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
May 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer?
*
*
Source and Credits
This presentation is based on the May 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sidney W.A. Dekker, Ph…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
October 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case October 2004
Thin Air
Source and Credits
This presentation is based on the Oct. 2004
AHRQ WebM&M Spotlight Case in Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: David M. Gaba, MD, Stanford Univer…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.110_slideshow.ppt
December 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case December 2005
Low on the Totem Pole
Source and Credits
This presentation is based on the Dec. 2005
Spotlight Case in Surgery/Anesthesia
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Robert Wachter, MD, …
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - The authors are solely
responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - Conclusions and Future Directions While the ACA increased the number of insured individuals and there … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - Conclusions and Future Directions While the ACA increased the number of insured individuals and there … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - Additional studies have come to similar conclusions. 1 The high demand for qualified nurses has outpaced … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
April 24, 2024 - Additional studies have come to similar conclusions. 1 The high demand for qualified nurses has outpaced … The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/primer/digital-health-literacy
August 30, 2023 - The authors are solely responsible for this report’s contents, findings, and conclusions, which do not
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psnet.ahrq.gov/sites/default/files/2024-10/The%20Different%20Count%20Contributions%20to%20Retention.pdf
January 01, 2024 - The Different Count Contributions to Retention
Differential Count Contributions in Retained Surgical Sponge Cases: Examination of Administrative Penalty
Cases from the California Department of Public Health (CDPH), Health and Safety Code Section 1280.1
Enforcement Reports from 2007-2014
A NoThing Left Behin…