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psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - X-ray Flip
Citation Text:
Shapiro MJ. X-ray Flip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Downl…
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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…
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psnet.ahrq.gov/node/863641/psn-pdf
February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training
February 28, 2024
Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…
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psnet.ahrq.gov/node/33719/psn-pdf
October 01, 2011 - The Context Is the Intervention
October 1, 2011
Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/context-intervention
Perspective
Introduction
What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this
context.…
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psnet.ahrq.gov/node/49465/psn-pdf
December 22, 2021 - Electronic Err
October 1, 2004
Tang PC. Electronic Err. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/electronic-err
The Case
A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest
pain that that had not responded to three sublingual nitroglycerin tablets at…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
September 01, 2012 - Spotlight Case July 2008
Spotlight Case
Peripheral IV in Too Long
1
2
Source and Credits
This presentation is based on the September 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Chi-Tai Fang, MD, PhD; Associate Professor, National Taiwan Uni…
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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psnet.ahrq.gov/node/33628/psn-pdf
February 01, 2006 - In Conversation with…John Banja, PhD
February 1, 2006
In Conversation with…John Banja, PhD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
Editor's Note: John Banja, PhD, is Assistant Director for Health Sciences and Clinical Ethics and
Associate Professor of Clinical Et…
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psnet.ahrq.gov/node/49680/psn-pdf
March 01, 2013 - Pathologic Mistake
March 1, 2013
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/pathologic-mistake
The Case
A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The
discomfort worsened with eating. After losing 15 pounds …
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psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not
Interchangeable
September 27, 2023
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
The Case
A fourteen-ye…
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psnet.ahrq.gov/node/49589/psn-pdf
August 01, 2009 - Hiding in Plain Sight
August 1, 2009
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/hiding-plain-sight
The Case
A 65-year-old woman presented to an emergency department (ED) with 48 hours of nontraumatic left lower
back pain and general malaise. She was diagnosed with a …
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psnet.ahrq.gov/node/853080/psn-pdf
August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting
Workforce Challenges
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. Virtual Nursing: Improving Patient Care and Meeting Workforce
Challenges. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workf…
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psnet.ahrq.gov/web-mm/misleading-complaint
December 01, 2009 - Misleading Complaint
Citation Text:
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
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psnet.ahrq.gov/web-mm/near-miss-neonate
August 15, 2018 - Near Miss With Neonate
Citation Text:
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/did-we-forget-something
April 28, 2021 - Did We Forget Something?
Citation Text:
Gibbs VC. Did We Forget Something?. 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/primer/electronic-health-records
March 15, 2025 - Electronic Health Records
Citation Text:
Electronic Health Records. 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/individual-clinician-performance-issues
March 15, 2025 - Individual Clinician Performance Issues
Citation Text:
Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
September 01, 2006 - Spotlight Case September 2006
Spotlight Case September 2006
Triple Handoff
Source and Credits
This presentation is based on the September 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: Arpana Vidyarthi, MD, UCSF Sc…
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psnet.ahrq.gov/node/49788/psn-pdf
March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A
Pharmacist Intervention
March 1, 2017
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
The Case
A 48-year…