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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
    December 01, 2014 - PowerPoint Presentation Spotlight A Stroke of Error This presentation is based on the December 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74022/psn-pdf
    March 01, 2021 - The Role of Community Pharmacists in Patient Safety October 25, 2021 Luchen GG, Hall KK, Hough KR. The Role of Community Pharmacists in Patient Safety . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety What is a community pharmacy? Community pharmacies are somet…
  3. psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
    November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn Citation Text: Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49793/psn-pdf
    May 01, 2017 - Hemolysis Holdup May 1, 2017 Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hemolysis-holdup The Case A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
  5. psnet.ahrq.gov/web-mm/polypharmacy
    March 01, 2007 - Polypharmacy Citation Text: Guglielmo JB. Polypharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
    July 01, 2011 - Spotlight Case July 2008 Spotlight Case Watch the Warfarin! 1 2 Source and Credits This presentation is based on the July 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Raman Khanna, MD, and Margaret Fang, MD, MPH; University of California, Sa…
  7. Psn-Pdf (pdf file)

    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…
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
    November 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case November 2005 Reconciling Doses Source and Credits This presentation is based on the November 2005 Spotlight Case in Emergency Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Frank Federico, RPh,…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49541/psn-pdf
    August 21, 2007 - Mark My Tooth August 21, 2007 Smith RA. Mark My Tooth. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/mark-my-tooth The Case A 45-year-old healthy man was scheduled to have two teeth extracted for progressive dental caries. The patient underwent the extractions, awoke from the anesthesia, and then realized…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49500/psn-pdf
    January 01, 2006 - Confusion With Acetaminophen January 1, 2006 Heubi JE. Confusion With Acetaminophen. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/confusion-acetaminophen The Case Parents brought their 5-year-old son to the emergency department (ED) with a 24-hour history of fever, cough, and frontal headache. Physical e…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49667/psn-pdf
    October 01, 2012 - Looking for Meds in All the Wrong Places October 1, 2012 Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places The Case A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She went to t…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33713/psn-pdf
    June 01, 2011 - The Safety of Medical Devices June 1, 2011 Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/safety-medical-devices Perspective Edward Tenner is right. Technology does have reverberations, including unintended consequences, or "revenge effects."(1) While such dra…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49743/psn-pdf
    September 01, 2015 - Dual Therapy Debacle September 1, 2015 Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/dual-therapy-debacle The Case An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction, hyperlipidemia, obesity, and a long history of tobacco use …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33790/psn-pdf
    August 01, 2015 - New Insights on Safety and Health IT August 1, 2015 Hettinger ZA, Ratwani RM, Fairbanks RJ. New Insights on Safety and Health IT. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/new-insights-safety-and-health-it Perspective Despite the widespread adoption of electronic health records (EHRs) over the las…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49421/psn-pdf
    October 01, 2003 - Urine a Tough Position October 1, 2003 Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/urine-tough-position The Case A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although she did not want to have a baby at that time, she sta…
  16. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
    June 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case June 2004 The Wrong Shot: Error Disclosure Source and Credits This presentation is based on the June 2004 AHRQ WebM&M Spotlight Case in Pediatrics CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Commentary by: Thomas H. …
  17. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
    June 01, 2014 - PowerPoint Presentation Spotlight Wandering Off the Floors: Safety and Security Risks of Patient Wandering 1 This presentation is based on the June 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Thomas A. Smith, CHPA, CPP, President, Healthc…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33606/psn-pdf
    December 15, 2024 - Opioid Safety December 15, 2024 Opioid Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/opioid-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 2024. Bac…
  19. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
    February 01, 2017 - PowerPoint Presentation Spotlight The Hazards of Distraction: Ticking All the EHR Boxes * Source and Credits This presentation is based on the February 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.14_slideshow.ppt
    May 01, 2003 - PowerPoint Presentation Spotlight Case May 2003 Central Line Complications in an Infant webmm.ahrq.gov Source and Credits This presentation is based on the May 2003 AHRQ WebM&M Spotlight Case in Pediatrics See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary…

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