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psnet.ahrq.gov/node/865570/psn-pdf
April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program:
Applying a Proactive Approach With Data Review &
Collaborating With a Second Practitioner
April 10, 2024
https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-
approach-data
Summary
North American Partners…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/web-mm/overriding-considerations
March 09, 2009 - Overriding Considerations
Citation Text:
Holtzman NA. Overriding Considerations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/web-mm/flying-object-hits-mri
September 01, 2005 - Flying Object Hits MRI
Citation Text:
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
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psnet.ahrq.gov/node/853981/psn-pdf
September 27, 2023 - Walking Out of a Hospital After Attempted Suicide
September 27, 2023
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
The Case
A 42-year-old man with history of posttraumatic stress disorder …
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model
to Advance Patient Safety in Care Transitions
November 16, 2022
Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to
Advance Patient Safety in Care Transitions . PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspecti…
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psnet.ahrq.gov/node/49575/psn-pdf
November 01, 2008 - Sick and Pregnant
November 1, 2008
El-Ibiary S. Sick and Pregnant. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/sick-and-pregnant
The Case
A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty
breathing. The patient informed the staff that she was 17 weeks pre…
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psnet.ahrq.gov/web-mm/moved-too-soon
November 01, 2006 - Moved Too Soon
Citation Text:
Lindenauer PK. Moved Too Soon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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…
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psnet.ahrq.gov/web-mm/listen-family
April 15, 2015 - Listen to the Family
Citation Text:
Campbell D. Listen to the Family. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
September 01, 2006 - Spotlight Case September 2006
Spotlight Case September 2006
Triple Handoff
Source and Credits
This presentation is based on the September 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: Arpana Vidyarthi, MD, UCSF Sc…
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Chemotherapy Administration Safety Standards
Citation Text:
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - Inadvertent Castration
January 1, 2004
Calland FJ. Inadvertent Castration. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/inadvertent-castration
The Case
An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently
increased in size. The patient described persisten…
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psnet.ahrq.gov/node/49854/psn-pdf
February 01, 2019 - Diagnostic Failure: The Growing Deficit
February 1, 2019
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
The Case
A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…
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psnet.ahrq.gov/node/61080/psn-pdf
October 28, 2020 - Preventing Complications during Aneurysm Clipping –
the Role of Neuromonitoring.
October 28, 2020
DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
…
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/node/33633/psn-pdf
May 01, 2006 - Patient Safety in the Physician Office Setting
May 1, 2006
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
Perspective
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - Chest Tube Complications
June 1, 2017
Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/chest-tube-complications
The Case
A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a
spontaneous left pneumothorax (coll…
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psnet.ahrq.gov/node/49761/psn-pdf
May 01, 2016 - The Fluidity of Diagnostic "Wet Reads"
May 1, 2016
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
The Case
A 64-year-old man with heavy tobacco use presented to the emergency department (ED) with chest pain.
His electroc…