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psnet.ahrq.gov/node/49707/psn-pdf
April 01, 2014 - communication had been significantly better than it was, there is always the chance of a key piece
of data falling
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psnet.ahrq.gov/node/33685/psn-pdf
May 01, 2009 - Where do you see the translation falling short?
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
December 01, 2014 - PowerPoint Presentation
Spotlight
A Stroke of Error
This presentation is based on the December 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…
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psnet.ahrq.gov/web-mm/mark-my-limb
February 10, 2015 - Mark My Limb
Citation Text:
Jacott WE, O'Leary D. Mark My Limb. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - Looking for Meds in All the Wrong Places
October 1, 2012
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
The Case
A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She
went to t…
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psnet.ahrq.gov/node/33713/psn-pdf
June 01, 2011 - The Safety of Medical Devices
June 1, 2011
Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/safety-medical-devices
Perspective
Edward Tenner is right. Technology does have reverberations, including unintended consequences, or
"revenge effects."(1) While such dra…
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psnet.ahrq.gov/node/33655/psn-pdf
August 01, 2007 - The PeaceHealth Governance Journey in Support of
Quality and Safety
August 1, 2007
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
Perspective
In recent years, the…
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psnet.ahrq.gov/node/33606/psn-pdf
December 15, 2024 - Opioid Safety
December 15, 2024
Opioid Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/opioid-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 patient safety field. Last reviewed in 2024.
Bac…
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psnet.ahrq.gov/node/33726/psn-pdf
March 01, 2012 - In Conversation With… Richard C. Boothman, JD
March 1, 2012
In Conversation With… Richard C. Boothman, JD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
Editor's note: Rick Boothman, an attorney, is the chief risk officer for the University of Michigan Health
System…
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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - SPOTLIGHT CASE
Beeline to Spine
Citation Text:
Smetana GW. Beeline to Spine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/node/49537/psn-pdf
June 01, 2007 - Beeline to Spine
June 1, 2007
Smetana GW. Beeline to Spine. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/beeline-spine
Case Objectives
Understand the elements of preoperative medical evaluation.
Appreciate the limited role for preoperative laboratory testing.
Appreciate the importance of communication a…
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - In Conversation With... Anjali Joseph, PhD, EDAC and
Molly M. Scanlon, PhD, FAIA, FACHA
June 30, 2021
In Conversation With.. Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-
…
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - Courts will usually respect a medical decision if a rationale that falls within a reasonable range of
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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - the finding
before recommending management limited to routine mammography screening.”12 BI-RADS 3 falls
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psnet.ahrq.gov/node/49585/psn-pdf
May 01, 2009 - infection (such as catheter-associated urinary tract infection or aspiration pneumonia), pressure ulcers,
falls
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psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - minute
Oxygen saturation less than 88%
Development of a new arrhythmia
Mean arterial blood pressure falls
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psnet.ahrq.gov/classics
August 01, 2023 - )
Medical Complications
(93)
Nosocomial Infections
(50)
Patient Falls
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psnet.ahrq.gov/node/33766/psn-pdf
May 01, 2014 - make it problematic to generalize from the hand hygiene experience to let's
say trying to decrease falls
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - timely diagnosis); however, they remain challenging and progress to date on decreasing diagnostic errors falls
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - Based on the experiences of these authors, it typically falls on the patient/family and consulting diabetes