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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…
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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…
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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…
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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…
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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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…
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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/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,…
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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…
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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…
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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…
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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…
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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 …
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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…
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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…
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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. …
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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…
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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…
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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…
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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…