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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
    February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49390/psn-pdf
    February 01, 2003 - Flying Object Hits MRI February 1, 2003 Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/flying-object-hits-mri The Case A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an anesthesiologist, the child was receiving…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49590/psn-pdf
    January 01, 2010 - Is the Admission Drug Dose Too Low? August 1, 2009 Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low The Case A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to the hospit…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866395/psn-pdf
    July 23, 2024 - Rescue Improvement Conference Innovation Summary July 23, 2024 https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary Summary The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure to rescue with a particular focus on communication and com…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49387/psn-pdf
    February 01, 2003 - Patient Mix-Up February 1, 2003 Shojania KG. Patient Mix-Up. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/patient-mix The Case Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general medical service at an academic medical center. Overnight, another man wit…
  6. psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
    March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events Citation Text: Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33593/psn-pdf
    June 15, 2024 - Measurement of Patient Safety June 15, 2024 Measurement of Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/measurement-patient-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 …
  8. psnet.ahrq.gov/primer/measurement-patient-safety
    September 15, 2024 - Measurement of Patient Safety Citation Text: Measurement of 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…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33565/psn-pdf
    September 01, 2024 - Healthcare-associated Infections June 15, 2024 Healthcare - Associated Infections. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/health-care-associated-infections PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice …
  10. psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - SPOTLIGHT CASE Intubation Mishap Citation Text: Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/84413/psn-pdf
    February 23, 2022 - A Loss of Trust and a Missed Diagnosis February 23, 2022 Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counci…
  12. psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
    July 23, 2024 - Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL December 22, 2020 Innovation Contact …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33796/psn-pdf
    January 01, 2016 - In Conversation With… Mark L. Graber, MD January 1, 2016 In Conversation With… Mark L. Graber, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-mark-l-graber-md Editor's note: Dr. Graber is a Senior Fellow at RTI International and Professor Emeritus of Medicine at the State University o…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867651/psn-pdf
    February 26, 2025 - Safety I, Safety II, and the New Views of Safety February 26, 2025 Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety Background and Context Safety I and Safety II (Safety I/II) are not safety method…
  15. psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
    July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications Save Save to your library Print Download PDF Sha…
  16. psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
    May 26, 2021 - Endometriosis: A Common and Commonly Missed and Delayed Diagnosis Citation Text: Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cit…
  17. psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
    October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…
  18. psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
    March 27, 2024 - SPOTLIGHT CASE Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head Citation Text: Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
  19. psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
    October 02, 2024 - Safety I, Safety II, and the New Views of Safety Citation Text: Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX E…
  20. psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
    January 04, 2024 - Retained Surgical Items: Causation and Prevention Citation Text: Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX End…

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