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psnet.ahrq.gov/node/49617/psn-pdf
January 01, 2011 - Failure to Reevaluate
December 1, 2010
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/failure-reevaluate
The Case
A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community
hospital developed methicillin-resistant staphylococc…
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psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - "Superficial" Report Leads to "Deep" Problem
December 1, 2009
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
The Case
A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…
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psnet.ahrq.gov/node/49556/psn-pdf
March 01, 2008 - Hold That Order
March 1, 2008
Grissinger M. Hold That Order. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/hold-order
The Case
A 25-year-old woman with a history of a pituitary tumor was admitted with hypernatremia. Because of her
previous pituitary resection and radiation, the patient had a long history …
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psnet.ahrq.gov/web-mm/insert-omission
May 09, 2014 - Insert Omission
Citation Text:
Darney P. Insert Omission. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
November 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case November 2006
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Source and Credits
This presentation is based on the November 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
June 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case June 2005
Getting to the Root of the Matter
Source and Credits
This presentation is based on the June 2005
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Scott Flanders, MD; Sa…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
December 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case December 2004
Discharge Fumbles
Source and Credits
This presentation is based on the Dec. 2004
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Alan Forster, M…
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psnet.ahrq.gov/node/850362/psn-pdf
June 14, 2023 - Home Medications Contribute to a Unique Opportunity for
Error on Discharge from the Hospital
June 14, 2023
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from
the Hospital. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…
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psnet.ahrq.gov/web-mm/communication-consultants
October 01, 2018 - Communication With Consultants
Citation Text:
Cohn SL. Communication With Consultants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/mark-my-tooth
June 01, 2014 - Mark My Tooth
Citation Text:
Smith RA. Mark My Tooth. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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D…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
View more articles from the same authors.
Citation Text:
Conway JB, Weingart SN. Organizational Change…
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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - Primary Care and Patient Safety: Opportunities at the
Interface
September 28, 2022
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
Editor’s Not…
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA
May 1, 2009
Also Read an Essay
Citation Text:
In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/node/74226/psn-pdf
February 01, 2019 - Veterans Health Administration Stratification Tool for
Opioid Risk Mitigation (STORM) Shows Promise for
Targeting Prevention Interventions to Reduce Mortality in
Patients Who Are Prescribed Opioids
January 7, 2022
https://psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-miti…
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psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
October 30, 2024 - Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids
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psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
May 01, 2009 - Patient Safety: A Perspective from Office Practice
Richard J. Baron, MD | May 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Baron RJ. Patient Safety: A Perspective from Office Practice. PSNet [internet]. Rockville (MD…
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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - SPOTLIGHT CASE
Do Not Miss Sepsis Needles in Viral Haystacks!
Citation Text:
Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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For…
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - SPOTLIGHT CASE
Premature Closure: Was It Just Syncope?
Citation Text:
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - Do Not Miss Sepsis Needles in Viral Haystacks!
March 27, 2024
Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accredit…
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psnet.ahrq.gov/node/846935/psn-pdf
March 29, 2023 - Maternal Safety and Perinatal Mental Health
March 29, 2023
Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
Maternal patient safety is a critical aspect of healthcare given the complex pr…