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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
    November 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case November 2008 Dangerous Shift Source and Credits This presentation is based on the November 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Emily S. Patterson, PhD Institute for Ergonomics, Ohi…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49689/psn-pdf
    August 21, 2013 - Anesthesia: A Weighty Issue August 21, 2013 Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/anesthesia-weighty-issue The Case A 77-year-old woman was evaluated preoperatively in anticipation of an elective left hip arthroplasty. She reported having a history of hyperte…
  3. psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
    November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn Citation Text: Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49416/psn-pdf
    September 01, 2003 - Check the Bags September 1, 2003 Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-bags The Case A 50-year-old man with new atrial fibrillation was placed on a diltiazem drip in the emergency department for rate control. After arriving at the cardiac care unit (CCU…
  5. psnet.ahrq.gov/web-mm/cultural-dimensions-depression
    September 01, 2018 - Cultural Dimensions of Depression Citation Text: Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33739/psn-pdf
    October 01, 2012 - The Physical Environment: An Often Unconsidered Patient Safety Tool October 1, 2012 Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool Perspective Now that…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49837/psn-pdf
    August 01, 2018 - Abdominal Aortic Aneurysm Screening August 1, 2018 Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening Case Objectives Describe risk factors associated with abdominal aortic aneurysm. Identify patient populations meeting criteria fo…
  8. psnet.ahrq.gov/web-mm/air-side-caution
    April 21, 2015 - Air on the Side of Caution Citation Text: Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49422/psn-pdf
    November 01, 2003 - 40 of K November 1, 2003 Lesar TS. 40 of K. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/40-k The Case An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
  10. psnet.ahrq.gov/web-mm/critical-opportunity-lost
    February 17, 2017 - Critical Opportunity Lost Citation Text: Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
  11. psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
    October 01, 2008 - Evaluating the patient safety indicators: how well do they perform on Veterans Health Administration … Sections Perspective Related Resources From the Same Author(s) Evaluating
  12. psnet.ahrq.gov/perspective/adverse-events-dentistry
    December 22, 2020 - opportunities exist to consider how to improve patient safety in this care setting. 1 Barriers to Evaluating … PubMedId RIS Download Citation Sections Introduction Barriers to Evaluating
  13. psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
    March 15, 2023 - Evaluating the knowledge of endotracheal cuff pressure monitoring among critical care providers by palpation
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843051/psn-pdf
    February 01, 2023 - Evaluating risk factors for re-exploration due to postoperative neck hematoma after thyroid surgery:
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867599/psn-pdf
    January 22, 2025 - Assessing patient work system factors for medication management during transition of care among older adults: an observational study. January 22, 2025 Xiao Y, Hsu Y-J, Hannum SM, et al. Assessing patient work system factors for medication management during transition of care among older adults: an observational st…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865344/psn-pdf
    March 27, 2024 - Use of computerized physician order entry with clinical decision support to prevent dose errors in pediatric medication orders: a systematic review. March 27, 2024 Ruutiainen H, Holmström A-R, Kunnola E, et al. Use of computerized physician order entry with clinical decision support to prevent dose errors in pedia…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73445/psn-pdf
    June 30, 2021 - Moving beyond the weekend effect: how can we best target interventions to improve patient care? June 30, 2021 Marang-van de Mheen PJ, Vincent CA. Moving beyond the weekend effect: how can we best target interventions to improve patient care? BMJ Qual Saf. 2021;30(7):525-528. doi:10.1136/bmjqs-2020- 012620. https:…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45538/psn-pdf
    December 14, 2016 - Liquid medication errors and dosing tools: a randomized controlled experiment. December 14, 2016 Yin S, Parker RM, Sanders LM, et al. Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment. Pediatrics. 2016;138(4):e20160357. https://psnet.ahrq.gov/issue/liquid-medication-errors-and-dosing-to…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73287/psn-pdf
    May 19, 2021 - Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population. May 19, 2021 Harder VS, Plante TB, Koh I, et al. Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population. J Gen Intern Med. 2021;36(7):2013-2020. doi:1…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73978/psn-pdf
    October 20, 2021 - Preventing pregnancy-related mental health deaths: insights from 14 US maternal mortality review committees, 2008-17. October 20, 2021 Trost SL, Beauregard JL, Smoots AN, et al. Preventing pregnancy-related mental health deaths: insights from 14 US maternal mortality review committees, 2008-17. Health Aff (Millwoo…

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