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psnet.ahrq.gov/node/865658/psn-pdf
April 24, 2024 - Managing Care Challenges in a Group Home Setting: Is
Staffing Adequate for Unplanned Incidents?
April 24, 2024
Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for
Unplanned Incidents? PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/managing-care-challenges-group-…
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psnet.ahrq.gov/node/49476/psn-pdf
March 02, 2005 - Around the Block
March 1, 2005
Minichiello T. Around the Block. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/around-block
The Case
A 77-year-old woman with multiple medical problems was admitted to the hospital for an elective knee
replacement. The orthopedic surgeon, recognizing the risk of deep vein th…
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psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest
for Transparency in U.S. Hospitals' Patient Safety
Performance
April 1, 2010
Roberts LL, Ward MM, Evans TC. The Role of the National Quality Forum (NQF) in the Quest for
Transparency in U.S. Hospitals' Patient Safety Performance. PSNet [internet]. 2010.
ht…
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psnet.ahrq.gov/node/49703/psn-pdf
March 01, 2014 - After-Visit Confusion
March 1, 2014
Ventres W. After-Visit Confusion. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/after-visit-confusion
The Case
An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white
spots near her tongue. The patient's mother accompanied her …
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psnet.ahrq.gov/node/33847/psn-pdf
August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of
Northwest…
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psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - Methicillin-Resistant Staphylococcus aureus
April 1, 2008
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
Perspective
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 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: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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psnet.ahrq.gov/node/49670/psn-pdf
November 01, 2012 - Missed Pneumonia
November 1, 2012
Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/missed-pneumonia
The Case
A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic
chest pain. Review of systems was negative for cough or dy…
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psnet.ahrq.gov/node/33782/psn-pdf
March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety
Measurement Program?
March 1, 2015
Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? PSNet [internet].
2015.
https://psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
Perspective
Much…
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psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - The Dropped Lung
May 1, 2003
Heffner JR. The Dropped Lung. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dropped-lung
The Case
A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been
hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
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psnet.ahrq.gov/node/33673/psn-pdf
September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety
September 1, 2008
Rothschild JM, Keohane C. The Role of Bar Coding and Smart Pumps in Safety. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
Perspective
Medication safety in hospitals depends on the successful execu…
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psnet.ahrq.gov/web-mm/over-not-so-easy
April 01, 2005 - Over Not So Easy
Citation Text:
Cucina R. Over Not So Easy. 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 tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49837/psn-pdf
August 01, 2018 - Abdominal Aortic Aneurysm Screening
August 1, 2018
Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
Case Objectives
Describe risk factors associated with abdominal aortic aneurysm.
Identify patient populations meeting criteria fo…
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psnet.ahrq.gov/node/49641/psn-pdf
November 01, 2011 - Liver Failure After Chemotherapy: Did We Forget
Something?
November 1, 2011
Lubel J. Liver Failure After Chemotherapy: Did We Forget Something? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
The Case
A 51-year-old Cantonese-speaking female with a his…
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psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - Workaround Error
Citation Text:
Pape T. Workaround Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/33699/psn-pdf
August 01, 2010 - Operationalizing Patient Safety at Academic Medical
Centers
August 1, 2010
Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet
[internet]. 2010.
https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
Perspective
Academic medical…
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psnet.ahrq.gov/node/33685/psn-pdf
May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA
May 1, 2009
In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and
Family M…
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psnet.ahrq.gov/node/49715/psn-pdf
August 21, 2014 - Liver Biopsy: Proceed With Caution
August 21, 2014
Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
The Case
A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast
cancer, presented t…
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
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D…
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psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room
January 29, 2021 - Is that solution for IV or irrigation?: Fluid administration errors in the operating room.
Citation Text:
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…