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  1. psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
    February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Essay View more articles from the same authors. Citation Text: Savitz LA, S…
  2. psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
    February 26, 2025 - Learning Health Systems for Patient Safety Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Savitz LA, Sousane Z, Mossburg SE. Learning …
  3. psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
    September 29, 2021 - and utility in patients with lower extremity injuries. 9 Early research into the use of IO lines focused
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33827/psn-pdf
    February 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS February 1, 2017 Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps Perspective Ten years ago, the Ag…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49503/psn-pdf
    February 01, 2006 - Workaround Error February 1, 2006 Pape T. Workaround Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/workaround-error The Case A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospita…
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
    October 01, 2010 - Spotlight Case July 2008 Spotlight Case October 2010 Dangerous Dialysis * * Source and Credits This presentation is based on the October 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33848/psn-pdf
    December 01, 2017 - The Evolution of Patient Safety in Surgery December 1, 2017 Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/evolution-patient-safety-surgery Perspective In 1979, 20 years before the Institute of Medicine's To Err Is Human report (1) catalyzed the cr…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33679/psn-pdf
    January 01, 2009 - Disclosure of Medical Error January 1, 2009 Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/disclosure-medical-error Perspective Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater discl…
  9. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
    November 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfusion Overload 1 2 Source and Credits This presentation is based on the November 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …
  10. psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
    January 01, 2016 - Charcoal Lavage of the Lungs Citation Text: Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49467/psn-pdf
    December 01, 2004 - A "Weak" Response December 1, 2004 Reisman AB. A "Weak" Response. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/weak-response The Case A primary care physician on call for his group received a call at 9:00PM from a 68-year-old man. He said, "They started me on a new pill for my blood pressure and now I fe…
  12. psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx Spotlight When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Source and Credits • This presentation is based on the September 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psne…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49404/psn-pdf
    June 01, 2003 - Not a Miscarriage June 1, 2003 Learman LA. Not a Miscarriage. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/not-miscarriage The Case A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49505/psn-pdf
    March 01, 2006 - Collegiality vs. Competence March 1, 2006 Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/collegiality-vs-competence The Case A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective repair of a 10-cm abdominal aortic aneurys…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60548/psn-pdf
    May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020 In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food…
  16. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
    February 01, 2014 - PowerPoint Presentation Spotlight Case Multifactorial Medication Mishap 1 This presentation is based on the February 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Annie Yang, PharmD, BCPS NYU Langone Medical Center Editor, AHRQ WebM&M: Robe…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49477/psn-pdf
    April 01, 2005 - Hold the tPA April 1, 2005 Fagan SC. Hold the tPA. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hold-tpa The Case A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49634/psn-pdf
    September 01, 2011 - Situational (Un)Awareness September 1, 2011 Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/situational-unawareness The Case A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver function tests, including a bi…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33829/psn-pdf
    March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety March 1, 2017 Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49839/psn-pdf
    August 01, 2018 - Mixup Beyond the Medication Label August 1, 2018 Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label The Case An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another hospi…

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