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  1. psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
    January 29, 2021 - SPOTLIGHT CASE A Missed Bowel Perforation - the Importance of Diagnostic Reasoning Citation Text: Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865697/psn-pdf
    April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges April 24, 2024 Leary KB. In Conversation with..Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-a…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33638/psn-pdf
    August 01, 2006 - Getting Into Patient Safety: A Personal Story August 1, 2006 Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/getting-patient-safety-personal-story Perspective My journey into patient safety began in 1972. It was born of serendipity enabled by the…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33689/psn-pdf
    October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety October 1, 2009 Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety Perspective …
  5. 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…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49727/psn-pdf
    March 01, 2015 - Critical Opportunity Lost March 1, 2015 Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/critical-opportunity-lost The Case A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She reported eating a heavy dinner the pre…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49449/psn-pdf
    June 01, 2004 - Lethal Vertigo June 1, 2004 Furman JM. Lethal Vertigo. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-vertigo The Case A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and vomiting, without headache. Her initial blood pressure in the emergency departme…
  8. 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…
  9. Spotlight (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.443_slideshow.ppt
    May 01, 2018 - Spotlight Spotlight Out of Sight, Out of Mind: Out-of-Office Test Result Management 1 Source and Credits This presentation is based on the May 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Eric Poon, MD, MPH, Duke University School o…
  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/49838/psn-pdf
    August 01, 2018 - An Untimely End Despite End-of-Life Care Planning August 1, 2018 Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning The Case A 76-year-old man was admitted to the intensive care unit (…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33684/psn-pdf
    May 01, 2009 - Patient Safety: A Perspective from Office Practice May 1, 2009 Baron RJ. Patient Safety: A Perspective from Office Practice. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice Perspective Most patient interactions with the health care system occur in the outpatien…
  13. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
    April 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case April 2008 Antibiotics for URI/Sinusitis: A Simple Decision Gone Bad Source and Credits This presentation is based on the April 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Sumant Ranji, MD,…
  14. psnet.ahrq.gov/web-mm/communication-consultants
    October 01, 2018 - Communication With Consultants Citation Text: Cohn SL. Communication With Consultants. 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 Endnot…
  15. psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
    June 16, 2021 - Looking for Meds in All the Wrong Places Citation Text: Manias E. Looking for Meds in All the Wrong Places. 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…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61080/psn-pdf
    October 28, 2020 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. October 28, 2020 DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74242/psn-pdf
    January 07, 2022 - The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps January 7, 2022 Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps The Case A 52-year-old woman w…
  18. psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
    March 12, 2021 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport Citation Text: MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849598/psn-pdf
    May 31, 2023 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023 https://psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve- management-sepsis Summary Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidiscip…
  20. psnet.ahrq.gov/perspective/safety-and-medical-education
    December 01, 2013 - Annual Perspective Safety and Medical Education Sumant Ranji, MD | January 1, 2014  Also Read a Conversation View more articles from the same authors. Citation Text: Ranji SR. Safety and Medical Education. PSNet [internet]. Rockville (MD): Agency for Healt…

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