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psnet.ahrq.gov/node/33744/psn-pdf
February 01, 2013 - By identifying strengths, the opportunity exists for patients and families to learn,
acquire information
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psnet.ahrq.gov/node/33674/psn-pdf
February 01, 2009 - do-ahrq-patient-safety-indicators-flag-conditions-are-present-time-hospital-admission
https://psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
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psnet.ahrq.gov/curated-library/organizational-learning
August 11, 2025 - can be used to process unstructured patient safety event reports and reduce the burden of manually identifying
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - patient, a family's online access to the hospital course could make a significant difference in terms of identifying
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - care, critical care, rheumatology, pulmonology, and oncology, should be aware of the importance of identifying
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - euglycemic, and approximately 15% of patients with DKA had more than one episode during pregnancy. 3 Identifying
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psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
January 13, 2021 - February 14, 2017
Identifying and reconciling patients' allergy information within the
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - Identifying and preventing medical errors in patients with limited English proficiency: key findings
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - The Dropped Lung
Citation Text:
Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - New Patient Mistakenly Checked in as Another
Citation Text:
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. 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/60543/psn-pdf
May 27, 2020 - Wrong Catheter in the Right Patient
May 27, 2020
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
The Case
A 55-year-old man with history of emphysema was admitted to the hospital for pneumonia. The patient had
two?peripheral…
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psnet.ahrq.gov/node/49433/psn-pdf
June 23, 2021 - Environmental Safety in the OR
February 1, 2004
Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/environmental-safety-or
The Case
The infection control department of a hospital noticed a marked increase in the rates of post-operative
sternal wound inf…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.296_slideshow.ppt
April 01, 2013 - Spotlight Case July 2008
Spotlight Case
Total Parenteral Nutrition, Multifarious Errors
*
*
Source and Credits
This presentation is based on the April 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph I. Boullata, PharmD, RPh, BCNSP…
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psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - Undetected Foreign Object
September 1, 2012
Cima RR. Undetected Foreign Object. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/undetected-foreign-object
The Case
A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension,
and diabetes was found to have obstruct…
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psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
June 16, 2021 - Adverse Event During Intrahospital Transport
Citation Text:
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/reconciling-records
September 01, 2017 - Reconciling Records
Citation Text:
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD
September 1, 2011
Also Read an Essay
Citation Text:
In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please
Teryl K. Nuckols, MD, MSHS | September 1, 2011
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Nuckols TK. Incident Reporting: More Attention to the …
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psnet.ahrq.gov/node/44166/psn-pdf
October 13, 2015 - Development and validation of electronic health
record–based triggers to detect delays in follow-up of
abnormal lung imaging findings.
October 13, 2015
Murphy DR, Thomas EJ, Meyer AND, et al. Development and Validation of Electronic Health Record-based
Triggers to Detect Delays in Follow-up of Abnormal Lung Imagin…
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psnet.ahrq.gov/node/867345/psn-pdf
December 11, 2024 - Implementation of a high-reliability organization
framework in a large integrated health care system: a pre-
post quasi-experimental quality improvement project.
December 11, 2024
Sawyer AM, Thiyarajan S, Essen KE, et al. Implementation of a high-reliability organization framework in a
large integrated health care…