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psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - Health Plan Patient Safety Initiatives
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024
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Citation Text:
Helwig A, Sousane Z, Mossburg S. Health Plan Patient S…
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psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
April 24, 2018 - Written Signout: It Only Works If You Use The Right One
Citation Text:
Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/back-again
November 18, 2016 - SPOTLIGHT CASE
Back Again
Citation Text:
Lurie JD. Back Again. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - In Conversation With... Cindy Brach
December 27, 2019
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Citation Text:
In Conversation With.. Cindy Brach. PSNet [internet]. 2019.In Conversation With... Cindy Brach. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
May 01, 2018 - In Conversation with…David W. Bates, MD, MSc
May 1, 2008
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Citation Text:
In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008…
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - SPOTLIGHT CASE
Fatal Error in Neonate: Does "Just Culture" Provide an Answer?
Citation Text:
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …
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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/49770/psn-pdf
September 01, 2016 - Wrong-Time Error With High-Alert Medication
September 1, 2016
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
The Case
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - SPOTLIGHT CASE
Adolescent Diabetes: A Routine Visit?
Citation Text:
Slap GB. Adolescent Diabetes: A Routine Visit?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - SPOTLIGHT CASE
Antiseizure Medication Disorder
Citation Text:
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - SPOTLIGHT CASE
CME/MOC
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…
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - SPOTLIGHT CASE
Transfer Troubles
Citation Text:
Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/periodic-issue/weekly-resource
February 26, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/web-mm/cardiac-arrest-woman-uti-case-qt-prolongation
March 27, 2024 - Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation
Citation Text:
Kulig CE, Ebong IA. Cardiac Arrest in a Woman with UTI: A Case of QT Prolongation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49391/psn-pdf
February 01, 2003 - When "Psychiatric" Symptoms Are Not
February 1, 2003
Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
The Case
A 70-year-old man without documented past psychiatric history was placed on an involuntary hold as a
danger to oth…
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psnet.ahrq.gov/node/49736/psn-pdf
June 01, 2015 - Inflicting Confusion
June 1, 2015
Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/inflicting-confusion
The Case
A 26-year-old man with recently diagnosed Crohn disease presented to the emergency department with
acute-onset abdominal pain, nausea, vomiting, an…
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psnet.ahrq.gov/node/49704/psn-pdf
March 01, 2014 - Late Anemia Following Rh Disease in a Newborn
March 1, 2014
Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
The Case
A full-term neonate was delivered uneventfully to an Rh-negative woman who had re…
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psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
August 01, 2015 - New Insights on Safety and Health IT
A. Zach Hettinger, MD, MS; Raj Ratwani, PhD; Rollin J. (Terry) Fairbanks, MD, MS | August 1, 2015
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Citation Text:
Hettinger ZA, Ratwani RM, Fairbanks RJ. New …
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - Annual Perspective
Diagnostic Errors
Urmimala Sarkar, MD; Kaveh Shojania, MD | January 1, 2014
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Citation Text:
Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - SPOTLIGHT CASE
Elopement
Citation Text:
Gerardi D. Elopement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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