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  1. 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. Copy Citation Format: …
  2. 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…
  3. Psn-Pdf (pdf file)

    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…
  4. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  5. psnet.ahrq.gov/curated-library/maternal-safety
    January 31, 2024 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Maternal Safety  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team …
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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 …
  8. 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. Copy Citation Format: Google Scholar BibTeX EndN…
  9. 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
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. 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…
  13. 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…
  14. Psn-Pdf (pdf file)

    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 …
  15. Psn-Pdf (pdf file)

    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
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850450/psn-pdf
    June 14, 2023 - Call the clinic for additional background information …” Identifying the treating outpatient physician
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837963/psn-pdf
    August 31, 2022 - Identifying Risks to Patient Safety The PCP, gastroenterologist, and endocrinologist did not fully consider
  18. 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. Copy Citation Format:…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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