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psnet.ahrq.gov/web-mm/mark-my-limb
February 10, 2015 - Mark My Limb
Citation Text:
Jacott WE, O'Leary D. Mark My Limb. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/node/73106/psn-pdf
April 01, 2021 - Strategies and Approaches for Tracking Improvements in
Patient Safety
April 1, 2021
Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
Background
An essential aspect …
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - Alert Fatigue
Citation Text:
Alert Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/high-reliability
January 29, 2020 - High Reliability
Citation Text:
High Reliability. 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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Downl…
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psnet.ahrq.gov/node/49412/psn-pdf
September 01, 2003 - Shake Well
September 1, 2003
Flynn EA. Shake Well. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/shake-well
The Case
A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily
serum drug levels consistently fell below the therapeutic range, which led the physi…
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psnet.ahrq.gov/node/49559/psn-pdf
April 01, 2008 - The Forgotten Drip
April 1, 2008
Josephson AS. The Forgotten Drip. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/forgotten-drip
The Case
A 45-year-old man was brought to the emergency department by his friends because of a 1-day history of a
severe headache and "bizarre behavior." A computed tomography (C…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
December 01, 2011 - Spotlight Case July 2008
Spotlight Case
Order Interrupted by Text: Multitasking Mishap
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Source and Credits
This presentation is based on the December 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John Halamka, MD, MS, Chief Informa…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
October 01, 2011 - Spotlight Case [MONTH] 2003
Spotlight Case
Mobility Lost in the ICU
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Source and Credits
This presentation is based on the October 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jim Smith, PT, DPT, MA; Associate Professor of Physical …
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psnet.ahrq.gov/node/33725/psn-pdf
February 01, 2012 - Balancing Supervision and Autonomy: An Ongoing
Tension
February 1, 2012
Dine JC, Myers JS. Balancing Supervision and Autonomy: An Ongoing Tension. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
Perspective
Graduate Medical Education (GME) has changed …
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psnet.ahrq.gov/node/49460/psn-pdf
September 01, 2004 - Security Lapse
September 1, 2004
Mason D. Security Lapse. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/security-lapse
The Case
A medical student learned that the hospital's radiology image library was accessible throughout the
university's computer system, meaning that patient x-rays could be viewed in d…
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psnet.ahrq.gov/node/33585/psn-pdf
March 15, 2025 - Radiation Safety
March 15, 2025
Radiation Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/radiation-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2025…
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psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
August 01, 2018 - levels of learners.( 18 ) More than 96% of papers reviewed showed improved performance accuracy and decreased
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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - discussed in recent literature, the histories of oppression and racism in the US may be contributing to decreased
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psnet.ahrq.gov/web-mm/dependence-vs-pain
October 30, 2019 - morning, the patient's abdominal pain became severe, his tachycardia worsened, and his blood pressure decreased
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - AHRQ report , in 2010 there were 145 adverse events for every 1000 hospitalizations; in 2014 that rate decreased
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - types of RSI cases, such as retained surgical sponges, but it is unclear whether this incidence has decreased
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - handwritten prescriptions to easily readable (by humans and
computers) prescriptions significantly decreased
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - CPOE systems have decreased dosing error rates associated with weight-based dosing.
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - Using the Targeted Solutions Tool to improve hand hygiene compliance is associated with decreased
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - Over the past decade, antibiotic prescribing for ARIs has decreased in response to publicity and education