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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
Citation Text:
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…
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psnet.ahrq.gov/web-mm/peripheral-iv-too-long
September 15, 2011 - SPOTLIGHT CASE
Peripheral IV in Too Long
Citation Text:
Fang C-T. Peripheral IV in Too Long. 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/node/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…
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psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - Management of Cardiac Arrest in Unconventional
Locations.
May 16, 2022
Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
The Case
Case #1: An 80-year-old man with history of Parkins…
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psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
March 24, 2025 - In Conversation With… Rebecca Lawton, PhD
September 1, 2018
Citation Text:
In Conversation With… Rebecca Lawton, PhD. 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/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback
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February 28, 2024
Innovation
Conta…
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psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - Never Events
September 15, 2024
Never Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/never-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Backg…
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psnet.ahrq.gov/node/33577/psn-pdf
September 15, 2024 - Duty Hours and Patient Safety
September 15, 2024
Duty Hours and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/duty-hours-and-patient-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the …
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psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
March 01, 2019 - Susan Haas : It was from several experiences that I had.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case July 2007
Resuscitation Errors:
A Shocking Problem
Source and Credits
This presentation is based on the July 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Benjamin Abella, MD, MPhil, …
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psnet.ahrq.gov/node/33751/psn-pdf
January 01, 2014 - Strengthening the Business Case for Patient Safety
May 1, 2013
Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
Perspective
After more than a decade in the national spotlight, the problem of pati…
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psnet.ahrq.gov/node/33884/psn-pdf
July 01, 2019 - Emerging Safety Issues in Artificial Intelligence
July 1, 2019
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
Perspective
Background
Since the beginning of digital health records, there has bee…
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psnet.ahrq.gov/node/49610/psn-pdf
October 01, 2010 - "Recurrent" Appendicitis
October 1, 2010
Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/recurrent-appendicitis
The Case
An 85-year-old man presented to the emergency department (ED) with right lower quadrant pain. On
physical examination, the patient showed rebound t…
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psnet.ahrq.gov/primer/telehealth-and-patient-safety
July 27, 2022 - Telehealth and Patient Safety.
Citation Text:
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
D…
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psnet.ahrq.gov/issue/learning-action-guide-putting-learning-organization-work
July 24, 2018 - Book/Report
Classic
Learning in Action: A Guide to Putting the Learning Organization to Work.
Citation Text:
Learning in Action: A Guide to Putting the Learning Organization to Work. Garvin DA. Harvard Business Review Press, 2003.
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psnet.ahrq.gov/issue/involving-patients-improving-safety
July 10, 2013 - Book/Report
Involving Patients in Improving Safety.
Citation Text:
Involving Patients in Improving Safety. London, UK: The Health Foundation; January 2013.
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psnet.ahrq.gov/issue/quality-work-environments-nurse-and-patient-safety
December 18, 2018 - Book/Report
Quality Work Environments for Nurse and Patient Safety.
Citation Text:
Quality Work Environments for Nurse and Patient Safety. McGillis Hall L. Sudbury, MA: Jones and Bartlett Publishers; 2005. ISBN 9780763728809.
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psnet.ahrq.gov/issue/teamstepps-video-toolkit
April 06, 2022 - Toolkit
TeamSTEPPS Video Toolkit.
Citation Text:
TeamSTEPPS Video Toolkit. AHA Team Training and Project Firstline. Chicago, IL: American Hospital Association, Center for Disease Control and Prevention; July 2021.
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psnet.ahrq.gov/issue/operating-room-hazards-and-approaches-improve-patient-safety
September 13, 2023 - Review
Patient safety in the operating room.
Citation Text:
Patient safety in the operating room. Wahr JA. UpToDate. September 21, 2023.
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