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  1. psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
    January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging Citation Text: Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…
  2. psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
    January 13, 2021 - Delayed Sepsis Management Due to Ambiguous Allergy Citation Text: Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Schol…
  3. psnet.ahrq.gov/web-mm/duplicate-insulin-order
    May 04, 2012 - Duplicate Insulin Order Citation Text: Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. 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 Endn…
  4. psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Andrew P.J. …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49822/psn-pdf
    March 01, 2018 - Isolated Clot, Real Error March 1, 2018 Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/isolated-clot-real-error Case Objectives Appreciate that errors are common in the management of venous thromboembolism disease. Describe patients with venous thromboembolism i…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33771/psn-pdf
    August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety August 22, 2014 Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety Perspective The frontier of patient safety outside the hospital has y…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50611/psn-pdf
    October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing October 30, 2019 Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing Case Objectives List the most common errors associated with computerized…
  8. psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
    March 01, 2009 - May I Have Another?—Medication Error Citation Text: Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  9. psnet.ahrq.gov/web-mm/right-patient-wrong-sample
    June 01, 2004 - Right Patient, Wrong Sample Citation Text: Astion ML. Right Patient, Wrong Sample. 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 Endnote ta…
  10. psnet.ahrq.gov/perspective/implementing-fall-prevention-program
    November 29, 2023 - Implementing a Fall Prevention Program Frances Healey, RN, PhD | December 1, 2011  View more articles from the same authors. Citation Text: Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
  11. psnet.ahrq.gov/web-mm/mismanagement-delirium
    February 13, 2014 - Mismanagement of Delirium Citation Text: Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
  12. psnet.ahrq.gov/web-mm/pregnant-danger
    January 12, 2011 - Pregnant With Danger Citation Text: Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  13. psnet.ahrq.gov/web-mm/weighing-surgical-safety
    August 04, 2021 - SPOTLIGHT CASE Weighing In on Surgical Safety Citation Text: Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865455/psn-pdf
    March 27, 2024 - Communication During Transitions of Care March 27, 2024 Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/communication-during-transitions-care Introduction Inaccurate or untimely communication and ineffective teamwork in healthca…
  15. psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
    March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? Citation Text: Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. C…
  16. psnet.ahrq.gov/web-mm/signout-fallout
    November 16, 2022 - SPOTLIGHT CASE Signout Fallout Citation Text: Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
  17. psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
    April 19, 2023 - In Conversation With… Karl Bilimoria, MD, MS August 1, 2017  Citation Text: In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation …
  18. psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
    July 17, 2024 - SPOTLIGHT CASE Tough Call: Addressing Errors From Previous Providers Citation Text: Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49651/psn-pdf
    May 01, 2012 - The Perils of Cross Coverage May 1, 2012 Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/perils-cross-coverage Case Objectives Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and care transitions. Describe ed…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73642/psn-pdf
    August 25, 2021 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected August 25, 2021 Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect- unexpected …

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