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psnet.ahrq.gov/node/33860/psn-pdf
June 01, 2018 - Safety Considerations in Building a Point-of-Care
Ultrasound Program
June 1, 2018
Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
Perspective
At the American Colle…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
May 01, 2006 - Spotlight Case
Spotlight Case May 2006
Right? Left? Neither!
Source and Credits
This presentation is based on the May 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - Spotlight Case July 2008
Spotlight Case
All in the History
Source and Credits
This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Christopher Fee, MD, University of California, San Francisco
…
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - Secured But Not Always Safe
Citation Text:
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML …
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psnet.ahrq.gov/node/49449/psn-pdf
June 01, 2004 - Lethal Vertigo
June 1, 2004
Furman JM. Lethal Vertigo. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-vertigo
The Case
A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and
vomiting, without headache. Her initial blood pressure in the emergency departme…
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psnet.ahrq.gov/node/836942/psn-pdf
April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake
Patient: Risks of Improper Medication Labeling in an
Operating Room
April 27, 2022
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication
Labeling in an Operating Room. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-m…
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psnet.ahrq.gov/node/49456/psn-pdf
July 12, 2004 - Glucose Roller Coaster
July 1, 2004
Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/glucose-roller-coaster
The Case
A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was
significant for dialysis-dependent, end-stage kidney d…
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psnet.ahrq.gov/node/49542/psn-pdf
August 21, 2007 - Copy and Paste
August 21, 2007
Hersh WR. Copy and Paste. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/copy-and-paste
The Case
A 77-year-old woman was admitted to a teaching hospital with diarrhea and dehydration after completing
her fifth cycle of chemotherapy for ovarian cancer. Her only relevant past m…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case February 2006
Lost in Transition
Source and Credits
This presentation is based on the February 2006 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Christopher Beach, MD; Northwe…
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psnet.ahrq.gov/node/49826/psn-pdf
April 01, 2018 - Air on the Side of Caution
April 1, 2018
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/air-side-caution
The Case
A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of
breath and chest pain. A decision was m…
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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Specimen Almost Lost
November 1, 2017
Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/specimen-almost-lost
The Case
A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen.
She was admitted to the medicine service for further evalu…
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psnet.ahrq.gov/node/33659/psn-pdf
October 01, 2007 - Making Just Culture a Reality: One Organization's
Approach
October 1, 2007
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
Perspective
We've all been there...something goes wrong,…
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psnet.ahrq.gov/node/33676/psn-pdf
November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH
November 1, 2008
In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
Editor's note: Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann
Arbor VA …
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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 …
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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…
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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…
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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…
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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…
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
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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, …