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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.368_slideshow.ppt
    February 01, 2016 - PowerPoint Presentation Spotlight Robotic Surgery: Risks vs. Rewards 1 Source and Credits This presentation is based on the February 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Tara Kirkpatrick, MD, and Chad LaGrange, MD, Univer…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865658/psn-pdf
    April 24, 2024 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents? April 24, 2024 Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents? PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/managing-care-challenges-group-…
  3. psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
    August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia Citation Text: Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cita…
  4. psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
    February 26, 2025 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 29, 2023 Innovation Co…
  5. psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
    January 01, 2024 - Spotlight Spotlight Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations 1 Source and Credits This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: David…
  6. psnet.ahrq.gov/innovation/awareness-human-factors-operating-theatres-during-covid-19-pandemic
    January 13, 2021 - EMERGING INNOVATIONS Awareness of human factors in the operating theatres during the COVID-19 pandemic Citation Text: Britton CR, Hayman G, Stroud N. Awareness of Human Factors in the operating theatres during the COVID-19 pandemic. Journal of Perioperative Practice. 2020;31(1-2). doi:10.1177/1750…
  7. psnet.ahrq.gov/issue/evaluation-association-between-nursing-home-survey-patient-safety-culture-nhsops-measures-and
    April 05, 2017 - Study Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures and catheter-associated urinary tract infections: results of a national collaborative. Citation Text: Smith SN, Greene MT, Mody L, et al. Evaluation of the association between Nurs…
  8. psnet.ahrq.gov/
    March 25, 2025 - This website is up to date as of March 24, 2025. You will not be able to register for an account and will no longer be able to obtain Continuing Medical Education (CME), Maintenance of Certification (MOC), or Continuing Pharmacy Education (CPE) credits. We are not taking submissions for WebM&M cases, Innovations, Train…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33576/psn-pdf
    December 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editoria…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33562/psn-pdf
    September 15, 2024 - Rapid Response Systems September 15, 2024 Rapid Response Systems. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/rapid-response-systems 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.…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72516/psn-pdf
    November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836892/psn-pdf
    April 07, 2022 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department April 7, 2022 https://psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely- intensive-care Summary An increasing volume…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836794/psn-pdf
    March 31, 2022 - A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. March 31, 2022 Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-c…
  14. psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
    October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867653/psn-pdf
    February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evoluti…
  16. psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
    February 05, 2020 - Hypoxic Gas Supply from Cross-Connected Pipelines Citation Text: Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google S…
  17. psnet.ahrq.gov/web-mm/ebola-are-we-ready
    July 01, 2012 - Ebola: Are We Ready? Citation Text: Barsuk JH, Barnard C. Ebola: Are We Ready?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49504/psn-pdf
    March 01, 2006 - Liposuction Gone Awry March 1, 2006 Yates JA. Liposuction Gone Awry. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/liposuction-gone-awry The Case A 54-year-old man with HIV was referred to a plastic surgeon for cosmetic surgery. In the plastic surgeon’s office, he underwent neck and facial liposuction wit…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49662/psn-pdf
    August 01, 2012 - Wrong Turn through Colon: Misplaced PEG August 1, 2012 Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg The Case An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a pa…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49778/psn-pdf
    December 01, 2016 - One Dose, Two Errors December 1, 2016 Filice GA. One Dose, Two Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/one-dose-two-errors The Case A 65-year-old woman was admitted to the intensive care unit (ICU) with severe sepsis and respiratory failure secondary to community-acquired pneumonia. The pati…

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