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psnet.ahrq.gov/node/33738/psn-pdf
December 01, 2012 - In Conversation With... John G. Reiling, PhD
December 1, 2012
In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
Editor's note: John G. Reiling, PhD, is president and CEO of Safe by Design. Dr. Reiling consults with
hospitals and…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.101_slideshow.ppt
July 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case July 2005
Impatient Inpatient Dosing
Source and Credits
This presentation is based on the July 2005
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: Richard H. White…
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psnet.ahrq.gov/node/33885/psn-pdf
August 01, 2019 - In Conversation With… Susan Smith, MD
August 1, 2019
In Conversation With… Susan Smith, MD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-smith-md
Editor's note: Dr. Smith, a family medicine physician, is chief faculty practices officer for UCSF Health.
Over the past 3–4 years, the …
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psnet.ahrq.gov/node/49741/psn-pdf
September 01, 2015 - Abdominal Pain in Early Pregnancy
September 1, 2015
Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
Case Objectives
Recognize when nausea and vomiting in pregnancy is abnormal.
Identify the most common causes of non-obstetric a…
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psnet.ahrq.gov/node/49602/psn-pdf
April 01, 2010 - Anticoagulation: Held Too Long
April 1, 2010
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
The Case
A 68-year-old woman with a history of mitral valve replacement with a mechanical valve was admitted with
abdominal pain. Because of the…
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psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
September 30, 2011 - Safeguarding Diagnostic Testing at the Point of Care
Citation Text:
Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.113_slideshow.ppt
January 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case January 2006
An Ounce of Prevention
Source and Credits
This presentation is based on the Jan. 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Nils Kucher, MD; University Ho…
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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psnet.ahrq.gov/node/49455/psn-pdf
July 01, 2004 - The Worst Headache
July 1, 2004
Edlow JA. The Worst Headache. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/worst-headache
The Case
A 48-year-old woman with a history of migraine headaches and hypertension presented to her outpatient
clinic with a 4-day history of headache. While shopping 4 days earlier, …
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - Implementing a Patient Safety Program at a Large
National Health System
January 1, 2008
Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
Perspectiv…
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - Pseudo-obstruction But a Real Perforation
July 1, 2017
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
Case Objectives
Recognize acute colonic pseudo-obstruction and implement a medical management plan.
Ide…
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Transfer Troubles
June 1, 2012
Hains IM. Transfer Troubles. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/transfer-troubles
Case Objectives
Recognize that transfer of patients between hospitals is common.
Understand the frequency of errors and adverse events in the transfer of patients between hospitals.
…
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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - The University of Texas System Clinical Safety and
Effectiveness Course
February 1, 2011
Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and
Effectiveness Course. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…
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psnet.ahrq.gov/node/49543/psn-pdf
September 01, 2007 - Medication Reconciliation: Whose Job Is It?
September 1, 2007
Poon EG. Medication Reconciliation: Whose Job Is It? PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
Case Objectives
Appreciate the prevalence and impact of medication discrepancies at times of transition in …
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psnet.ahrq.gov/node/33805/psn-pdf
April 01, 2016 - In Conversation With… Thomas J. Nasca, MD, MACP
April 1, 2016
In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
Editor's note: Dr. Nasca is Chief Executive Officer of the Accreditation Council for Graduate Medical
Educat…
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psnet.ahrq.gov/node/50392/psn-pdf
September 01, 2019 - In Conversation With… Shantanu Agrawal, MD, MPhil
September 1, 2019
In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
Editor's note: Dr. Agrawal is president and CEO of the National Quality Forum (NQF). He is the form…
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psnet.ahrq.gov/continuing-education
February 26, 2025 - Continuing Education
What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …