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  1. 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 …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33882/psn-pdf
    June 01, 2019 - Building a Safety Program Using Principles of Resilience Engineering June 1, 2019 Hegde S, Fairbanks RJ, Bisantz A. Building a Safety Program Using Principles of Resilience Engineering. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering Persp…
  3. 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,…
  4. 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…
  5. 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…
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.356_slideshow.ppt
    September 01, 2015 - PowerPoint Presentation Spotlight Abdominal Pain in Early Pregnancy This presentation is based on the September 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Charlie C. Kilpatrick, MD, Associate Professor of Obstetrics and Gynecology, Baylor …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49509/psn-pdf
    April 01, 2006 - Insert Omission April 1, 2006 Darney P. Insert Omission. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/insert-omission The Case A multiparous woman presented to the gynecology clinic requesting intrauterine contraceptive (IUC) placement (Figure). She was appropriately counseled on the risks and benefits o…
  8. 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 …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49692/psn-pdf
    September 01, 2013 - A Picture Speaks 1000 Words September 1, 2013 Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words The Case A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection repair presented with chest p…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33655/psn-pdf
    August 01, 2007 - The PeaceHealth Governance Journey in Support of Quality and Safety August 1, 2007 Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety Perspective In recent years, the…
  11. 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…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49689/psn-pdf
    August 21, 2013 - Anesthesia: A Weighty Issue August 21, 2013 Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/anesthesia-weighty-issue The Case A 77-year-old woman was evaluated preoperatively in anticipation of an elective left hip arthroplasty. She reported having a history of hyperte…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49511/psn-pdf
    May 01, 2006 - Citrate Mix-Up May 1, 2006 Weber RJ. Citrate Mix-Up. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/citrate-mix The Case A 36-year-old woman with multiple sclerosis, diabetes, and chronic renal failure was transferred from a skilled nursing facility (SNF) to the hospital for treatment of an infection. On a…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33755/psn-pdf
    September 01, 2013 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety September 1, 2013 Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
  15. psnet.ahrq.gov/primer/reporting-patient-safety-events
    March 30, 2022 - Reporting Patient Safety Events Citation Text: Reporting Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
  16. psnet.ahrq.gov/primer/duty-hours-and-patient-safety
    June 15, 2024 - Duty Hours and Patient Safety Citation Text: Duty Hours and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33854/psn-pdf
    March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety March 1, 2018 Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety Perspective Errors in hospitals remain a major cause of death.(1…
  18. Psn-Pdf (pdf file)

    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…
  19. psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
    March 10, 2021 - LH: As we’ve discussed, some of these measures can easily become check-the-box metrics, and I am not
  20. psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
    November 25, 2020 - SPOTLIGHT CASE A Laceration that Needed a Proper Exam, Not an X-Ray Citation Text: Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Cit…

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