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  1. 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…

  2. Rss

    psnet.ahrq.gov/weekly-resource/rss.xml
    January 01, 2024 - PSNet PSNet PSNet Weekly Resource (Review) The role of AI in detecting and mitigating human errors in safety-critical industries: a review. Artificial intelligence (AI) and machine learning (ML) are being used and tested in numerous ways. This review highlights how they are being used to detect and mitigate human err…

  3. 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: …

  4. 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…

  5. 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, …

  6. 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…

  7. 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 – Opioid …

  8. 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…

  9. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations | PSNet

    psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
    September 27, 2023 - SPOTLIGHT CASE Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations Citation Text: Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

  10. 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…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853902/psn-pdf
    September 27, 2023 - A Missed Bowel Perforation - the Importance of Diagnostic Reasoning September 27, 2023 Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning Disclosure of …

  12. 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 …

  13. In Conversation With… Richard Kronick, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
    February 01, 2014 - In Conversation With… Richard Kronick, PhD February 1, 2014  Also Read an Essay Citation Text: In Conversation With… Richard Kronick, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…

  14. Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx Spotlight A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion Source and Credits • This presentation is based on the July 2023 AHRQ WebM&M Spotlight Case o See the full article at ht…

  15. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care | PSNet

    psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
    January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care Paul E. Plsek, MS | January 1, 2015  Also Read a Conversation View more articles from the same authors. Citation Text: Plsek PE. Innovation and Lean Thinking: Mutuall…

  16. In Conversation With… Mark Graban, MS, MBA | PSNet

    psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
    January 01, 2015 - In Conversation With… Mark Graban, MS, MBA January 1, 2015  Also Read an Essay Citation Text: In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851568/psn-pdf
    July 31, 2023 - A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion July 31, 2023 Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomid…

  18. Are We Safer Today? | PSNet

    psnet.ahrq.gov/perspective/are-we-safer-today
    February 26, 2025 - Are We Safer Today? David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Bates DW, Lee M, Mossburg SE. Are We Safer Today?. PSNet [in…

  19. In Conversation with David W. Bates about Are We Safer Today? | PSNet

    psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
    February 26, 2025 - In Conversation with David W. Bates about Are We Safer Today? David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Essay View more articles from the same authors. Citation Text: Bates DW, Lee M, Mossburg…

  20. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion | PSNet

    psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
    June 14, 2023 - SPOTLIGHT CASE A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion Citation Text: Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality…
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