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psnet.ahrq.gov/node/848125/psn-pdf
April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in
Acute Hospital Care Units
April 26, 2023
McGrath S, Blike G, Gale B, et al. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care
Units. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-…
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psnet.ahrq.gov/node/50701/psn-pdf
November 26, 2019 - In Conversation With... Heidi Wald, MD
November 26, 2019
In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-heidi-wald-md
Editor’s note: Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO.
She has previously served as …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.317_slideshow.ppt
March 01, 2014 - PowerPoint Presentation
Spotlight Case
Tough Call: Addressing Errors From Previous Providers
1
This presentation is based on the March 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: William Martinez, MD, MS, Assistant Professor of Medicine, …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.155_slideshow.ppt
July 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case July 2007
Resuscitation Errors:
A Shocking Problem
Source and Credits
This presentation is based on the July 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Benjamin Abella, MD, MPhil, …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
July 01, 2012 - Spotlight Case July 2008
Spotlight Case
Not-So-Therapeutic Tap
*
*
Source and Credits
This presentation is based on the July 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeffrey H. Barsuk, MD, MS; Northwestern University Feinberg Scho…
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psnet.ahrq.gov/node/33625/psn-pdf
January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions
Remain
January 1, 2006
Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
Perspective
On August 2, 2005, Air France flig…
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psnet.ahrq.gov/node/49484/psn-pdf
June 01, 2005 - Two Pills, Same Drug
June 1, 2005
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/two-pills-same-drug
The Case
A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past
medical history included several AIDS-related complica…
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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/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/node/72693/psn-pdf
January 29, 2021 - Unintentional Ketamine Overdose in the Operating Room
– Mixing Up the Ampules
January 29, 2021
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
The Case
A…
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psnet.ahrq.gov/node/33786/psn-pdf
May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational
Uses
May 1, 2015
Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet
[internet]. 2015.
https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
Perspective
Reports of…
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psnet.ahrq.gov/web-mm/air-side-caution
April 21, 2015 - Air on the Side of Caution
Citation Text:
Robertson JM, Pozner CN. Air on the Side of Caution. 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 XML EndNote 7 XM…
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
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psnet.ahrq.gov/web-mm/amphotericin-toxicity
April 01, 2014 - Amphotericin Toxicity
Citation Text:
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
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psnet.ahrq.gov/node/49434/psn-pdf
February 01, 2004 - Undiagnosed Vaginal Bleeding
February 1, 2004
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
The Case
The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal
bleeding. Over the past…
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psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable
Citation Text:
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Ci…
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psnet.ahrq.gov/node/49407/psn-pdf
July 01, 2003 - Bleeding Risk
July 1, 2003
Crowther MA. Bleeding Risk. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/bleeding-risk
The Case
A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial
fibrillation, hypertension, coronary artery disease, and stroke. The surgi…
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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/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
January 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case January 2008
How Do Providers Recover from Errors?
Source and Credits
This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Colin P. West, MD, PhD, Mayo Clini…
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psnet.ahrq.gov/node/33884/psn-pdf
July 01, 2019 - Emerging Safety Issues in Artificial Intelligence
July 1, 2019
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
Perspective
Background
Since the beginning of digital health records, there has bee…