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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - April 15, 2009
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - April 27, 2016
Evaluation of clinical practice guidelines on fall prevention and management
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psnet.ahrq.gov/node/861881/psn-pdf
January 31, 2024 - /nursing.gwu.edu/center-health-policy-and-media-engagement
https://psnet.ahrq.gov//#1
improvement fall
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psnet.ahrq.gov/node/33696/psn-pdf
June 01, 2010 - Does it help that you're aware of the
possible holes that you may fall into, or are there more specific
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
February 26, 2025 - on whether those solutions were adopted and whether or not they were effective, that's where things fall
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psnet.ahrq.gov/issue/effort-human-factors-performance-and-decision-making
August 31, 2022 - Commentary
Effort in human factors performance and decision making.
Citation Text:
Wickens CD. Effort in human factors performance and decision making. Hum Factors. 2014;56(8):1329-36.
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psnet.ahrq.gov/issue/risky-business-navigating-shifting-health-care-landscape
December 22, 2021 - Meeting/Conference Proceedings
Risky Business: Navigating a Shifting Health Care Landscape.
Citation Text:
Boston Children’s Hospital. April 15, 2021.
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psnet.ahrq.gov/issue/five-pitfalls-decisions-about-diagnosis-and-prescribing
April 26, 2017 - Commentary
Five pitfalls in decisions about diagnosis and prescribing.
Citation Text:
Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005;330(7494):781-3.
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psnet.ahrq.gov/issue/resistance-patient-safety-initiatives
November 26, 2014 - Newspaper/Magazine Article
Resistance to patient safety initiatives.
Citation Text:
O'Connor EJ, Fiol M. Resistance to patient safety initiatives. Physician executive. 2005;31(6):64-7.
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psnet.ahrq.gov/issue/patient-safety-mindful-meaningful-and-fulfilling
October 20, 2021 - Commentary
Patient safety: mindful, meaningful, and fulfilling.
Citation Text:
Winokur SC, Beauregard KJ. Patient safety: mindful, meaningful, and fulfilling. Front Health Serv Manage. 2005;22(1):17-32.
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psnet.ahrq.gov/issue/evaluating-service-delivery-interventions-enhance-patient-safety
June 18, 2008 - Study
Evaluating service delivery interventions to enhance patient safety.
Citation Text:
Brown C, Lilford RJ. Evaluating service delivery interventions to enhance patient safety. BMJ. 2008;337:a2764. doi:10.1136/bmj.a2764.
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DOI Google Scholar PubMed …
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psnet.ahrq.gov/periodic-issue/periodic-issue-452
August 28, 2024 - August 14, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports…
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psnet.ahrq.gov/periodic-issue/periodic-issue-436
April 10, 2024 - April 17, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/periodic-issue/periodic-issue-434
April 10, 2024 - April 3, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/node/49638/psn-pdf
January 01, 2012 - Communication Failure—Who's in Charge?
October 1, 2011
Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge
The Case
A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - PowerPoint Presentation
Spotlight
A Pill Organizing Plight
*
Source and Credits
This presentation is based on the September 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Ro…
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - A Mistaken Dose of Naloxone?
December 18, 2019
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
The Case
A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up
appointment. He h…
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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - Eptifibatide Epilogue
April 1, 2009
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue
The Case
A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute
coronary syndrome. Serial testing for mark…
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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Baffled by Botulinum Toxin
Citation Text:
Sivaraman-Nair KP. Baffled by Botulinum Toxin. 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/patient-safety-and-adherence-self-administered-medications
September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications
Citation Text:
Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011…