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psnet.ahrq.gov/node/33780/psn-pdf
July 01, 2015 - Safety and Medical Education
January 1, 2014
Ranji SR. Safety and Medical Education. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/safety-and-medical-education
Annual Perspective 2014
As the patient safety field has grown, so too has the appreciation for the need to improve safety in medical
educatio…
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psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
December 01, 2005 - Introducing the Redesigned AHRQ Patient Safety Network
Robert M. Wachter, MD | November 1, 2015
View more articles from the same authors.
Citation Text:
Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.14_slideshow.ppt
May 01, 2003 - PowerPoint Presentation
Spotlight Case May 2003
Central Line Complications in an Infant
webmm.ahrq.gov
Source and Credits
This presentation is based on the May 2003
AHRQ WebM&M Spotlight Case in Pediatrics
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary…
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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…
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - Alert Fatigue
Citation Text:
Alert Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Ci…
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psnet.ahrq.gov/node/72836/psn-pdf
January 26, 2021 - Meaningful Measurement in Patient and Family
Engagement
March 10, 2021
Hoy L, Hoy S, Fitall E, et al. Meaningful Measurement in Patient and Family Engagement. PSNet [internet].
2021.
https://psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
Defining Patient and Family Engagement
Pat…
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - SPOTLIGHT CASE
Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture
Citation Text:
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - Unseen Perils of Urinary Catheters
Citation Text:
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room.
Citation Text:
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - SPOTLIGHT CASE
A Lot of Pain (Medications)
Citation Text:
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
Citation Text:
In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - SPOTLIGHT CASE
Total Parenteral Nutrition, Multifarious Errors
Citation Text:
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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…
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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
Hidden Heparins: HIT Happens
Citation Text:
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
February 01, 2006 - Removing Insult from Injury—Disclosing Adverse Events
Albert W. Wu, MD, MPH | February 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wu AW. Removing Insult from Injury—Disclosing Adverse Events. PSNet [internet]. Rock…
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - SPOTLIGHT CASE
Difficult Encounters: A CMO and CNO Respond
Citation Text:
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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…
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psnet.ahrq.gov/node/838197/psn-pdf
September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a
Plan.
September 28, 2022
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022.
https://psnet.…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
February 01, 2006 - In Conversation with…John Banja, PhD
February 1, 2006
Also Read an Essay
Citation Text:
In Conversation with…John Banja, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md
February 26, 2025 - In Conversation With… Shantanu Nundy, MD
July 1, 2018
Citation Text:
In Conversation With… Shantanu Nundy, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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