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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - Medication Reconciliation Pitfalls
Citation Text:
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/turn-other-cheek
October 26, 2010 - Turn the Other Cheek
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Starling J. Turn the Other Cheek. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
February 26, 2025 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV)
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June 30, 2021
Innovat…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
October 01, 2013 - PowerPoint Presentation
Spotlight Case
It's Sarah, not Stephen!
1
This presentation is based on the October 2013 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Urmimala Sarkar, MD, MPH, University of California at San Francisco
Editor, AHRQ WebM&…
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psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
December 01, 2014 - African Partnerships for Patient Safety: Lessons Learned
Shams B. Syed, MD, MPH | December 1, 2014
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Citation Text:
Syed SS. African Partnerships for Patient Safety: Lessons Learned. PSNet [intern…
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psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
January 31, 2024 - Patient Safety in Office-Based Care Settings
Richard Ricciardi, Ph.D., CRNP, FAANP, FAAN; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD
| January 31, 2024
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Citation Text:
Ricciardi R, L…
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psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
January 31, 2024 - In Conversation with...Richard Ricciardi about Office-Based Patient Safety
Richard Ricciardi, Ph.D., CRNP, FAANP, FAAN | January 31, 2024
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Citation Text:
Ricciardi R, Lee M, Mossburg S. In Conversatio…
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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
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Citation Text:
Plsek PE. Innovation and Lean Thinking: Mutuall…
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - investigated and understood; and how improvement actions can be organized and implemented to ensure safety is enhanced
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness
Suzanne Beyea, RN, PhD | February 1, 2014
Also Read the Conversations
In Conversation With… Enrico Coiera, MB, BS, PhD
In Conversation With… Richard Kronick, PhD
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - Improving patient safety and clinician workflow in the general care setting with enhanced surveillance
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psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
December 22, 2018 - Don't Use That Port: Insert a PICC
Citation Text:
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - Getting the Diagnosis Both Right and Wrong
September 25, 2019
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
The Case
A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - Managing Ascites: Hazards of Fluid Removal
Citation Text:
Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/forgotten-radiographic-read
June 07, 2016 - The Forgotten Radiographic Read
Citation Text:
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/860015/psn-pdf
September 01, 2024 - Retained Surgical Items: Definition and Epidemiology.
January 4, 2024
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
Background
Prudent medical practice and federal and state laws r…
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psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
March 01, 2004 - Video to Improve Patient Safety: Clinical and Educational Uses
Yan Xiao, PhD; Colin F. Mackenzie, MB, ChB; and F. Jacob Seagull, PhD | May 1, 2015
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Citation Text:
Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient S…
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psnet.ahrq.gov/web-mm/forgotten-med
July 01, 2006 - The Forgotten Med
Citation Text:
Cucina R. The Forgotten Med. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Premature or Overdue?
Citation Text:
Thomas J, Hannah M. Premature or Overdue?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/49794/psn-pdf
May 01, 2017 - Communication Error in a Closed ICU
May 1, 2017
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/communication-error-closed-icu
The Case
A 70-year-old man with a complex medical history including end-stage renal disease (status post kidney
transplant), co…