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psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
November 04, 2015 - Patient Safety in the Physician Office Setting
Nancy C. Elder, MD, MSPH | May 1, 2006
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Citation Text:
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable
Citation Text:
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - Complaints as Safety Surveillance
September 1, 2016
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain
came on sudden…
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psnet.ahrq.gov/node/49731/psn-pdf
April 01, 2015 - Fire in the Hole!—An OR Fire
April 1, 2015
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fire-hole-or-fire
The Case
A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection
for a biopsy-proven adenocarcinom…
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psnet.ahrq.gov/node/49736/psn-pdf
June 01, 2015 - Inflicting Confusion
June 1, 2015
Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/inflicting-confusion
The Case
A 26-year-old man with recently diagnosed Crohn disease presented to the emergency department with
acute-onset abdominal pain, nausea, vomiting, an…
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - Identifying Adverse Events Not Present on Admission: Can We Do It?
James M. Naessens, ScD | October 1, 2008
Also Read a Conversation
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Citation Text:
Naessens JM. Identifying Adverse Events Not Present on Admission: Can W…
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After
Emergency Cesarean Delivery.
November 30, 2021
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean
Delivery. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…
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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.
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Format:
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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - A Laceration that Needed a Proper Exam, Not an X-Ray
January 31, 2024
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
Disclosure of Relevant Financial Relationships: As a provider accredited by t…
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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - Spotlight
Spotlight
Laceration that Needed a Proper Exam, Not an X-Ray
Source and Credits
• This presentation is based on the January 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Jazmin A. Wander, MD and David K. Barnes, MD,
F…
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - Additionally, minimizing the time
she spent unsupervised in her room, which enabled opportunities for poor decision … -
making could be helpful
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psnet.ahrq.gov/sites/default/files/2024-11/spotlight_case_neurological_red_flags_final.pptx
January 01, 2024 - presentation contains several key features that need to be accounted for in the diagnosis and medical decision-making
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psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
February 08, 2023 - presentation contains several key features that need to be accounted for in the diagnosis and medical decision-making
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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/72614/psn-pdf
March 01, 2021 - Rehearsing Team Care for Relatively Rare Obstetric
Emergencies Leads to Improved Outcomes
Originally published on December 22, 2020
Last updated on December 23, 2020
https://psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-
improved-outcomes
Summary
Multidisciplinary tea…
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Lost in the Black Hole
Citation Text:
Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
May 01, 2011 - Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention
Citation Text:
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Cop…
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psnet.ahrq.gov/node/866216/psn-pdf
July 10, 2024 - Health Plan Patient Safety Initiatives
July 10, 2024
Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
When we think of improving patient safety, we often think of strategies that can be implemen…
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psnet.ahrq.gov/node/49417/psn-pdf
October 01, 2003 - Lost in the Black Hole
October 1, 2003
Wachter R. Lost in the Black Hole. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lost-black-hole
The Case
A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis.
She had a remote history of gonorrhea, no environmental exposu…
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psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
June 29, 2020 - Annual Perspective
Pharmacist Role in Patient Safety
February 21, 2020
View more articles from the same authors.
Citation Text:
Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…