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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
September 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case September 2007
Medication Reconciliation: Whose Job Is It?
Source and Credits
This presentation is based on the September 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Eric G. Poon, MD, MPH, Ha…
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - Risk Management and Patient Safety
December 1, 2010
Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety
Perspective
In 1990, a Harvard-based research team reported the incidence of medical errors …
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psnet.ahrq.gov/node/33745/psn-pdf
February 01, 2013 - Patient Engagement and Patient Safety
February 1, 2013
Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
Perspective
Patient engagement has arrived at the station. A Google search of this phrase identified 335,000 hi…
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psnet.ahrq.gov/node/49761/psn-pdf
May 01, 2016 - The Fluidity of Diagnostic "Wet Reads"
May 1, 2016
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
The Case
A 64-year-old man with heavy tobacco use presented to the emergency department (ED) with chest pain.
His electroc…
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psnet.ahrq.gov/node/866846/psn-pdf
September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 24, 2024
Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/zero…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
October 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case October 2007
Do Not Disturb!
Source and Credits
This presentation is based on the October 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: F. Daniel Duffy, MD, University of Oklahoma, and…
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psnet.ahrq.gov/node/73549/psn-pdf
July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee
Arthroplasty.
July 28, 2021
Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
The Case
A 61-year-old male patient weighing 57…
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Two Wrongs Don't Make a Right (Kidney)
March 1, 2015
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
Case Objectives
Review the current definition of wrong-site surgery.
Describe the incidence of wrong-site surgery, and the…
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psnet.ahrq.gov/node/33634/psn-pdf
May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia
May 1, 2006
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia.
PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
Perspective
Over the last decade, sur…
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Chemotherapy Administration Safety Standards
Citation Text:
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity
Simulation
March 1, 2006
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
Point–Counterpoint
Editor's Note…
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psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not
Interchangeable
September 27, 2023
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
The Case
A fourteen-ye…
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psnet.ahrq.gov/node/49686/psn-pdf
May 01, 2013 - Don't Use That Port: Insert a PICC
May 1, 2013
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
The Case
A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with
fever and abdominal pain. A comp…
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
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 s…
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Timely diagnosis of esophageal perforation
Citation Text:
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Format:
Google Scholar BibTeX …
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - Wrong Route for Nutrients
Citation Text:
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
January 01, 2015 - If You Say So: Taking a Syringe at Face Value in the Operating Room
Citation Text:
Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
August 30, 2023 - Strategies to Improve Organizational Health Literacy.
Citation Text:
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:…
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - Detection of Safety Hazards
Citation Text:
Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…