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  1. psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
    August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia Citation Text: Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  2. psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
    August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment Citation Text: Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citatio…
  3. psnet.ahrq.gov/web-mm/volume-too-low-and-out
    July 01, 2017 - SPOTLIGHT CASE Volume Too Low: In and Out Citation Text: Miller MR. Volume Too Low: In and Out . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49579/psn-pdf
    March 21, 2009 - All in the History March 21, 2009 Fee C. All in the History. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/all-history Case Objectives Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it does not apply to transfers to emergency departments from non-acute care faci…
  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
    January 01, 2020 - Spotlight Spotlight Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care Source and Credits • This presentation is based on the 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm • Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD ○ Editor…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73300/psn-pdf
    July 01, 2022 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care May 26, 2021 https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care Summary The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs,…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73200/psn-pdf
    April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions April 28, 2021 Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions The Case  A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and severe e…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49624/psn-pdf
    May 01, 2011 - Duty to Disclose Someone Else's Error? May 1, 2011 Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error Case Objectives State the rationale for disclosing medical errors. Describe key principles in effective error disclosure. …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49855/psn-pdf
    March 01, 2019 - Which Line: Ordering Provider or Proceduralist? March 1, 2019 Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist Case Objectives Review the role of mistake-proofing to block errors from leading to adverse…
  10. psnet.ahrq.gov/Information/Panel
    January 01, 2012 - Browse Author Resources Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
  11. psnet.ahrq.gov/primer/simulation-training
    September 15, 2024 - Simulation Training Citation Text: Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
  12. psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
    March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. Citation Text: Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
  13. psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
    January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia Citation Text: Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…
  14. psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
    July 10, 2024 - In Conversation with...Patrick S. Romano, MD, MPH November 1, 2010  Citation Text: In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.In Conversation with...Patrick S. Romano, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
  15. psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
    March 15, 2023 - SPOTLIGHT CASE False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. Citation Text: Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
  16. psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
    January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. Citation Text: Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…
  17. psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
    February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 26, 2021 Innovation Contact …
  18. psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
    January 17, 2018 - SPOTLIGHT CASE Physical Diagnosis: A Lost Art? Citation Text: Thompson GR, Verghese A. Physical Diagnosis: A Lost Art?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Schola…
  19. psnet.ahrq.gov/issue/implementation-custom-alert-prevent-medication-timing-errors-associated-computerized
    April 25, 2016 - Study Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry. Citation Text: Idemoto LM, Williams BL, Ching JM, et al. Implementation of a custom alert to prevent medication-timing errors associated with computerized presc…
  20. psnet.ahrq.gov/issue/learning-lawsuits-using-malpractice-claims-data-develop-care-transitions-planning-tools
    January 21, 2019 - Study Learning from lawsuits: using malpractice claims data to develop care transitions planning tools. Citation Text: Arbaje AI, Werner NE, Kasda EM, et al. Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools. J Patient Saf. 2020;16(1):52-57.…

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