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psnet.ahrq.gov/web-mm/over-not-so-easy
April 01, 2005 - Over Not So Easy
Citation Text:
Cucina R. Over Not So Easy. 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/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
March 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case March 2005
The Hidden Mystery
Source and Credits
This presentation is based on the March 2005
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Douglas D. Br…
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - Haste Makes Care Unsafe
January 1, 2015
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
The Case
An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined
elective coronary artery bypass graft (CABG…
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric
Patients at Risk of Physiologic Instability
December 23, 2020
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at
Risk of Physiologic Instability. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm…
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psnet.ahrq.gov/node/33772/psn-pdf
September 01, 2014 - In Conversation With… Rosemary Gibson, MSc
September 1, 2014
In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
Editor's note: Rosemary Gibson, MSc, is Senior Advisor to The Hastings Center and an editor for JAMA
Internal Medicin…
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psnet.ahrq.gov/node/49637/psn-pdf
October 01, 2011 - The Dropped "No"
October 1, 2011
Johnson AJ. The Dropped "No". PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropped-no
The Case
A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in
his legs. Because the leg swelling was somewhat more pronounced in his…
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psnet.ahrq.gov/training-catalog
June 01, 2025 - Training Catalog
The AHRQ PSNet Training Catalog is an easy to use resource for healthcare professionals across all settings of care and specialties looking for education opportunities to further their knowledge of patient safety practices and principles. Some training opportunities are available as in-person meeting…
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psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - Workaround Error
Citation Text:
Pape T. Workaround Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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…
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - Following his wishes, he transitioned to comfort-focused end-of-life care but remained in an inpatient
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - error is identified, institutions should consider root cause analyses
(RCAs) of the error and systems-focused
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psnet.ahrq.gov/node/845472/psn-pdf
March 15, 2023 - It allowed us to develop these programs because we were all focused on this one
disease at that time
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psnet.ahrq.gov/perspective/conversation-abraham-verghese-md
November 01, 2012 - In Conversation With… Abraham Verghese, MD
November 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… Abraham Verghese, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - dissection—diagnosis with
which emergency department physicians have little experience—was missed as physicians focused
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Lost in the Black Hole
Citation Text:
Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - Wrong-Time Error With High-Alert Medication
Citation Text:
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/849592/psn-pdf
May 31, 2023 - Preventing Falls Through Patient and Family Engagement
to Create Customized Prevention Plans
May 31, 2023
https://psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-
customized-prevention
Summary
Patient falls in hospitals are common and debilitating adverse events that persis…
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psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
July 02, 2011 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.
Citation Text:
DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
December 22, 2018 - Don't Use That Port: Insert a PICC
Citation Text:
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - Glucose Roller Coaster
Citation Text:
Sharpe B. Glucose Roller Coaster. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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