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  1. psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
    July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience Karen Frush, MD | May 1, 2005  View more articles from the same authors. Citation Text: Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
  2. psnet.ahrq.gov/web-mm/discharged-blindly
    October 26, 2022 - Discharged Blindly Citation Text: Iezzoni LI. Discharged Blindly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
  3. psnet.ahrq.gov/web-mm/insert-omission
    May 09, 2014 - Insert Omission Citation Text: Darney P. Insert Omission. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73554/psn-pdf
    July 28, 2021 - EMS Patient Safety in the Field July 28, 2021 Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/ems-patient-safety-field Introduction Emergency medical services (EMS) personnel serve a critical role within the care continuum. They ar…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49770/psn-pdf
    September 01, 2016 - Wrong-Time Error With High-Alert Medication September 1, 2016 Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication The Case A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
  6. Spotlight Case (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
    May 01, 2006 - Spotlight Case Spotlight Case May 2006 Right? Left? Neither! Source and Credits This presentation is based on the May 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD…
  7. psnet.ahrq.gov/web-mm/secured-not-always-safe
    October 01, 2015 - Secured But Not Always Safe Citation Text: Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33846/psn-pdf
    November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety November 1, 2017 Rozenblum R, Bates DW. The Role of Patient-facing Technologies to Empower Patients and Improve Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-imp…
  9. psnet.ahrq.gov/web-mm/misread-label
    August 28, 2024 - Misread Label Citation Text: Franklin BD. Misread Label. 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 tagged PubMedId RIS …
  10. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
    October 01, 2015 - PowerPoint Presentation Spotlight The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy 1 This presentation is based on the October 2015 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/ CME credit is available Commentary by: Jacob Reider,…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837785/psn-pdf
    August 05, 2022 - Emergence of Application-based Healthcare August 5, 2022 Marvel FA, Dowell P, Mossburg SE. Emergence of Application-based Healthcare. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/emergence-application-based-healthcare Introduction The demand for digital healthcare, including both telemedicine and hea…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49406/psn-pdf
    June 01, 2003 - The Dangerous Detour June 1, 2003 Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dangerous-detour The Case Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service for observation after being placed on a 72-hour hold by…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33623/psn-pdf
    December 01, 2005 - The Unintended Consequences of Florida Medical Liability Legislation December 1, 2005 Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation Perspective Quality health …
  14. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.92_slideshow.ppt
    April 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case April 2005 Compare and Contrast Source and Credits This presentation is based on the April 2005 Spotlight Case in Emergency Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Kerry Cho, MD; Glenn Cher…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49727/psn-pdf
    March 01, 2015 - Critical Opportunity Lost March 1, 2015 Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/critical-opportunity-lost The Case A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She reported eating a heavy dinner the pre…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33797/psn-pdf
    January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice January 1, 2016 Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33741/psn-pdf
    November 01, 2012 - The Evidence-Based Physical Examination as a Patient Safety Practice November 1, 2012 McGee S. The Evidence-Based Physical Examination as a Patient Safety Practice. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice Perspective Near the end of hi…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49456/psn-pdf
    July 12, 2004 - Glucose Roller Coaster July 1, 2004 Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/glucose-roller-coaster The Case A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was significant for dialysis-dependent, end-stage kidney d…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49659/psn-pdf
    July 01, 2012 - Sloppy and Paste July 1, 2012 Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/sloppy-and-paste The Case A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new onset chest pain. The ED physician reviewed the patient's electronic me…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49587/psn-pdf
    May 01, 2009 - Missing Trauma May 1, 2009 Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/missing-trauma The Case A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a few minutes later by a customer, who immediately called 911. On arrival, para…

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