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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
    January 01, 2022 - Spotlight Spotlight Intraosseous Line Extravasation in a Pediatric Trauma Patient Source and Credits • This presentation is based on the April 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: David Barnes, MD and Joseph Yoon, MD o…
  2. 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…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857061/psn-pdf
    November 27, 2023 - In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023 Stanley J. In Conversation with.. Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-joa…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73102/psn-pdf
    July 01, 2022 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use March 31, 2021 https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail- community-dwelling Summary Care management staff (such …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73128/psn-pdf
    July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. April 7, 2021 https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications- and-enhances Summary The Hospital at Homesm program provides hospital-level care…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33859/psn-pdf
    June 01, 2018 - In Conversation With… Richard Hoppmann, MD June 1, 2018 In Conversation With… Richard Hoppmann, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md Editor's note: Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor of Medicine, and Dire…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49483/psn-pdf
    June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…
  8. psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery Citation Text: Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
  9. psnet.ahrq.gov/web-mm/deadly-duo
    April 28, 2021 - The Deadly Duo Citation Text: Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  10. psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
    November 02, 2016 - Promising Areas for Patient Safety Research P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH | December 1, 2003  View more articles from the same authors. Citation Text: Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. …
  11. psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
    February 26, 2025 - In Conversation with...Brent C. James, MD, MStat February 1, 2011  Citation Text: In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011.In Conversation with...Brent C. James, MD, MStat. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
  12. psnet.ahrq.gov/print/pdf/node/845971
    January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Value and Patient Safety Curated Library Foundations Safety is the preservation of value. Vandeskog B. J Safety Res. 2024;89:105-115. Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety resea…
  13. psnet.ahrq.gov/web-mm/getting-root-matter
    September 01, 2005 - SPOTLIGHT CASE Getting to the Root of the Matter Citation Text: Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Schola…
  14. psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
    March 01, 2019 - Vision and Leadership Setting strategic goals and establishing values and a focus on safety at the
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49488/psn-pdf
    August 21, 2005 - PCA Overdose August 21, 2005 Doyle JD. PCA Overdose. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pca-overdose The Case A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo- oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49469/psn-pdf
    December 01, 2004 - Overriding Considerations December 1, 2004 Holtzman NA. Overriding Considerations. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/overriding-considerations The Case Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic testing for a variety of condition…
  17. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.287_slideshow.ppt
    December 01, 2012 - Spotlight Case July 2008 Spotlight Case The Lung Nodule That Refused To Grow * * Source and Credits This presentation is based on the December 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Alex A. Balekian, MD, MSHS, Keck School of Med…
  18. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
    December 01, 2015 - PowerPoint Presentation Spotlight Harm From Alarm Fatigue This presentation is based on the December 2015 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49697/psn-pdf
    December 01, 2013 - Check the Anesthesia Machine December 1, 2013 Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/check-anesthesia-machine The Case A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension, diabetes, sleep apnea…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49563/psn-pdf
    May 01, 2008 - Is It Safe to Be Direct? May 1, 2008 Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/it-safe-be-direct The Case   A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician (PCP) for progressive shortness of breat…

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