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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - Must be examined for risk and pilot-tested for workability.
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - identify the highest risk patients during care transitions, a new study by Glance and colleagues examined
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psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
July 01, 2004 - A study that examined the American College of Surgeons National Surgical Quality Improvement Program
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psnet.ahrq.gov/web-mm/no-blood-please
January 14, 2011 - No Blood, Please
Citation Text:
Liang BA. No Blood, Please. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/node/49499/psn-pdf
December 02, 2020 - An Outpatient 'Zebra'
January 1, 2006
Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/outpatient-zebra
The Case
A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness.
His past medical history included lumbar disc diseas…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
February 01, 2011 - Spotlight Case July 2008
Spotlight Case
One Toxic Drug Is Not Like Another
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*
Source and Credits
This presentation is based on the February 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Eric S. Holmboe, MD, American Board of Internal…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
May 01, 2011 - Spotlight Case July 2008
Spotlight Case
Duty to Disclose Someone Else’s Error
*
*
Source and Credits
This presentation is based on the May 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas H. Gallagher, MD University of Washington
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.95_slideshow.ppt
May 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case May 2005
Diagnosing Diagnostic Mistakes
Source and Credits
This presentation is based on the May 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: Robert McNutt, MD; Richard A…
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - patient about the duration of symptoms, character of nasal discharge, and presence of toothache, and examined
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - Early Ophthalmologic Exam The patient in this case was apparently not examined early for visual loss,
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - The anesthesia team examined the drawer and found vials of
cefazolin and vecuronium (a long-acting paralytic
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - Auerbach et al.15 and the TOPS (Triad for Optimal Patient Safety) project team examined how teamwork
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - The anesthesia team examined the drawer and found vials of cefazolin and vecuronium (a long-acting paralytic
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - exchange followed the physician out of the patient's room and politely informed him that he had in fact examined
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psnet.ahrq.gov/web-mm/nosy-business
March 01, 2007 - Nosy Business
Citation Text:
Orlandi RR. Nosy Business. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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…
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psnet.ahrq.gov/node/49399/psn-pdf
May 01, 2003 - Ectopic or Not?
May 1, 2003
Givens VM, Lipscomb GH. Ectopic or Not? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/ectopic-or-not
The Case
The patient is a 24-year-old woman, gravida 4, para 1, ectopic 1, at 6 weeks from her last menstrual period.
She presents to the emergency department with a 3-day histo…
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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - Delayed Breast Cancer Diagnosis: A False Sense of
Security.
December 23, 2020
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
The Case
A 60-year-old woman was se…
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psnet.ahrq.gov/print/pdf/node/838351
July 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Safety Improvement
Curated Library
Foundations
Improving Diagnosis in Health Care.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and
Medicine. Washington, DC: National Academies Press; …
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psnet.ahrq.gov/curated-library/value-and-patient-safety
October 30, 2019 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Value and Patient Safety
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Tea…
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…