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  1. Patient Safety Events Involving Opioid Dose Stacking | PSNet

    psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
    July 08, 2022 - SPOTLIGHT CASE Patient Safety Events Involving Opioid Dose Stacking Citation Text: Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Cita…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867206/psn-pdf
    December 18, 2024 - Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache December 18, 2024 Edlow J. Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-in…

  3. Medication Mix-Up: From Bad to Worse | PSNet

    psnet.ahrq.gov/web-mm/medication-mix-bad-worse
    March 01, 2018 - Medication Mix-Up: From Bad to Worse Citation Text: Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote …

  4. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. | PSNet

    psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
    July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. Citation Text: Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.. PSNet [internet]. Rockville (MD): A…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72911/psn-pdf
    March 15, 2021 - The Impact of Communication on Medication Errors March 15, 2021 Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors The Case   A 93-year-old man with a history of chronic systolic heart failure…

  6. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers | PSNet

    psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
    January 07, 2022 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers Citation Text: Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867805/psn-pdf
    February 26, 2025 - In Conversation with David W. Bates about Are We Safer Today? February 26, 2025 Bates DW, Lee M, Mossburg SE. In Conversation with David W. Bates about Are We Safer Today? PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today Editor’s note: David W. Bates, …

  8. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…

  9. Spotlight

    psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…

  10. The Need to Eat | PSNet

    psnet.ahrq.gov/web-mm/need-eat
    February 10, 2021 - The Need to Eat Citation Text: Widaman AM. The Need to Eat. 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 PubMedId RIS …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50755/psn-pdf
    December 18, 2019 - The Need to Eat December 18, 2019 Widaman AM. The Need to Eat. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/need-eat The Case A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…

  12. WebM&M: Case Studies | PSNet

    psnet.ahrq.gov/webmm-case-studies
    March 25, 2025 - WebM&M: Case Studies WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…

  13. Health Plan Patient Safety Initiatives | PSNet

    psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
    July 10, 2024 - Health Plan Patient Safety Initiatives Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024  Also Read the Conversation View more articles from the same authors. Citation Text: Helwig A, Sousane Z, Mossburg S. Health Plan Patient S…

  14. In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives | PSNet

    psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
    July 10, 2024 - In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024  Also Read the Essay View more articles from the same authors. Citation Text: Helwig A, Sousane Z, …

  15. The Impact of Communication on Medication Errors | PSNet

    psnet.ahrq.gov/web-mm/impact-communication-medication-errors
    August 01, 2009 - The Impact of Communication on Medication Errors Citation Text: Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867672/psn-pdf
    February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations February 26, 2025 Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. 2025. https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…

  17. What Makes a Good Checklist | PSNet

    psnet.ahrq.gov/perspective/what-makes-good-checklist
    October 01, 2010 - What Makes a Good Checklist Anne Collins McLaughlin, PhD | October 1, 2010  Also Read a Conversation View more articles from the same authors. Citation Text: McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

  18. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet

    psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
    January 29, 2021 - SPOTLIGHT CASE A Missed Bowel Perforation - the Importance of Diagnostic Reasoning Citation Text: Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867428/psn-pdf
    December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-patricia-dykes-a…

  20. AHRQ PSNet Webinar (pdf file)

    psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
    January 01, 2025 - AHRQ PSNet Webinar AHRQ PSNet Webinar Making Healthcare Safer (MHS) IV: Rapid Response Systems and Opioid Stewardship February 10, 2025 Agenda 2 • Logistics • Introduction to the Making Healthcare Safer (MHS) IV Reports • Report 1 – Rapid Response Systems ► Discussion ► PSNet Resources • Report 2 – Opioi…
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