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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - SPOTLIGHT CASE
Suicidal Ideation in the Family Medicine Clinic
Citation Text:
Moutier C. Suicidal Ideation in the Family Medicine Clinic. 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/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - SPOTLIGHT CASE
Right Regimen, Wrong Cancer: Patient Catches Medical Error
Citation Text:
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/node/851099/psn-pdf
June 28, 2023 - Misconnection Leading to Arterial Thrombosis
June 28, 2023
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
The Case
A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - SPOTLIGHT CASE
Isolated Clot, Real Error
Citation Text:
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Maternal Safety
Download
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
…
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - Missed Opportunities for Suicide Risk Assessment
November 27, 2019
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - Challenges of Diabetes Management and Medication
Reconciliation
August 5, 2022
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
The Cases
Case #1: A 53-year-old man …
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - SPOTLIGHT CASE
Palliative Care: Comfort vs. Harm
Citation Text:
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/medias-role-patient-safety
April 27, 2022 - : I’m thinking about it as a patient safety tool, like using it to identify clusters of events, or identifying … Related Resources From the Same Author(s)
Perspective
Identifying
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psnet.ahrq.gov/node/49821/psn-pdf
February 01, 2018 - Right Place, Right Drug, Wrong Strength
February 1, 2018
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
The Case
A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…
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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Did We Forget Something?
September 1, 2003
Gibbs VC. Did We Forget Something? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/did-we-forget-something
The Case
A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially
attributed to ventilator-associated pneumo…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
December 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case December 2004
Discharge Fumbles
Source and Credits
This presentation is based on the Dec. 2004
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: Alan Forster, M…
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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.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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psnet.ahrq.gov/node/49515/psn-pdf
July 01, 2006 - Over Not So Easy
July 1, 2006
Cucina R. Over Not So Easy. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/over-not-so-easy
The Case
A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On
admission, she reported allergies to a number of medications as well as a …
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - ventilator settings were applied, or the patient’s body habitus,
but this information would be useful in identifying
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psnet.ahrq.gov/node/850450/psn-pdf
June 14, 2023 - Call the clinic for additional background information …” Identifying the treating
outpatient physician
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - Identifying Risks to Patient Safety
The PCP, gastroenterologist, and endocrinologist did not fully consider
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psnet.ahrq.gov/issue/creating-culture-safety-opioid-prescribing-handbook-healthcare-executives
May 01, 2023 - Toolkit
Creating a Culture of Safety for Opioid Prescribing: A Handbook for Healthcare Executives.
Citation Text:
Centers for Disease Control and Prevention (CDC); 2021. Creating a Culture of Safety for Opioid Prescribing: A Handbook for Healthcare Executives.
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psnet.ahrq.gov/node/47530/psn-pdf
June 19, 2019 - Two decades since To Err Is Human: an assessment of
progress and emerging priorities in patient safety.
June 19, 2019
Bates DW, Singh H. Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging
Priorities In Patient Safety. Health Aff (Millwood). 2018;37(11):1736-1743. doi:10.1377/hlthaff.2018.0738…
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psnet.ahrq.gov/node/42245/psn-pdf
July 22, 2013 - 25-Year summary of US malpractice claims for diagnostic
errors 1986–2010: an analysis from the National
Practitioner Data Bank.
July 22, 2013
Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors
1986-2010: an analysis from the National Practitioner Data Bank. BMJ Q…