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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
    May 01, 2013 - Spotlight Case July 2008 Spotlight Case Right Regimen, Wrong Cancer: Patient Catches Medical Error * * Source and Credits This presentation is based on the May 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Joseph O. Jacobson, MD, MSc…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49421/psn-pdf
    October 01, 2003 - Urine a Tough Position October 1, 2003 Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/urine-tough-position The Case A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although she did not want to have a baby at that time, she sta…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49559/psn-pdf
    April 01, 2008 - The Forgotten Drip April 1, 2008 Josephson AS. The Forgotten Drip. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/forgotten-drip The Case A 45-year-old man was brought to the emergency department by his friends because of a 1-day history of a severe headache and "bizarre behavior." A computed tomography (C…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49509/psn-pdf
    April 01, 2006 - Insert Omission April 1, 2006 Darney P. Insert Omission. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/insert-omission The Case A multiparous woman presented to the gynecology clinic requesting intrauterine contraceptive (IUC) placement (Figure). She was appropriately counseled on the risks and benefits o…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867804/psn-pdf
    February 26, 2025 - Are We Safer Today? February 26, 2025 Bates DW, Lee M, Mossburg SE. Are We Safer Today? PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/are-we-safer-today In the 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (now the National Academy of Medicine) drew on two lar…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33755/psn-pdf
    September 01, 2013 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety September 1, 2013 Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33725/psn-pdf
    February 01, 2012 - Balancing Supervision and Autonomy: An Ongoing Tension February 1, 2012 Dine JC, Myers JS. Balancing Supervision and Autonomy: An Ongoing Tension. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension Perspective Graduate Medical Education (GME) has changed …
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
    October 01, 2011 - Spotlight Case [MONTH] 2003 Spotlight Case Mobility Lost in the ICU * * Source and Credits This presentation is based on the October 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jim Smith, PT, DPT, MA; Associate Professor of Physical …
  9. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
    June 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case June 2004 The Wrong Shot: Error Disclosure Source and Credits This presentation is based on the June 2004 AHRQ WebM&M Spotlight Case in Pediatrics CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Commentary by: Thomas H. …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49500/psn-pdf
    January 01, 2006 - Confusion With Acetaminophen January 1, 2006 Heubi JE. Confusion With Acetaminophen. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/confusion-acetaminophen The Case Parents brought their 5-year-old son to the emergency department (ED) with a 24-hour history of fever, cough, and frontal headache. Physical e…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49425/psn-pdf
    November 01, 2003 - Misread Label November 1, 2003 Franklin BD. Misread Label. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/misread-label The Case An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine [Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…
  12. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.326_slideshow.ppt
    June 01, 2014 - PowerPoint Presentation Spotlight Wandering Off the Floors: Safety and Security Risks of Patient Wandering 1 This presentation is based on the June 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Thomas A. Smith, CHPA, CPP, President, Healthc…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33872/psn-pdf
    January 01, 2018 - Update: Patient Engagement in Safety January 1, 2018 Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/update-patient-engagement-safety Annual Perspective 2018 Background Patient engagement has become a cornerstone of patient safety. A Patient Saf…
  14. psnet.ahrq.gov/primer/duty-hours-and-patient-safety
    June 15, 2024 - Duty Hours and Patient Safety Citation Text: Duty Hours and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
  15. psnet.ahrq.gov/perspective/update-patient-engagement-safety
    January 01, 2017 - Annual Perspective Update: Patient Engagement in Safety Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2018  View more articles from the same authors. Citation Text: Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. Rockvi…
  16. psnet.ahrq.gov/primer/triggers-and-trigger-tools
    September 15, 2024 - Triggers and Trigger Tools Citation Text: Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
  17. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
    July 01, 2011 - Spotlight Case July 2008 Spotlight Case Watch the Warfarin! 1 2 Source and Credits This presentation is based on the July 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Raman Khanna, MD, and Margaret Fang, MD, MPH; University of California, Sa…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33882/psn-pdf
    June 01, 2019 - Building a Safety Program Using Principles of Resilience Engineering June 1, 2019 Hegde S, Fairbanks RJ, Bisantz A. Building a Safety Program Using Principles of Resilience Engineering. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering Persp…
  19. psnet.ahrq.gov/web-mm/coming-short
    May 20, 2020 - Coming Up Short Citation Text: Hochberg Z'ev. Coming Up Short. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72516/psn-pdf
    November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…

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