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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
    September 01, 2006 - Spotlight Case September 2006 Spotlight Case September 2006 Triple Handoff Source and Credits This presentation is based on the September 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Arpana Vidyarthi, MD, UCSF Sc…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49424/psn-pdf
    November 01, 2003 - Waiting Too Long November 1, 2003 Rosen MA. Waiting Too Long. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/waiting-too-long The Case A 31-year-old gravida 1, para 1 woman presented at 40 weeks in the early stages of labor having received limited prenatal care at an outside clinic. Physical exam performed…
  3. psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
    March 30, 2016 - Chemotherapy Administration Safety Standards Citation Text: Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX En…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49686/psn-pdf
    May 01, 2013 - Don't Use That Port: Insert a PICC May 1, 2013 Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc The Case A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with fever and abdominal pain. A comp…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49622/psn-pdf
    March 01, 2011 - Dropping the Ball Despite an Integrated EMR March 1, 2011 Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr The Case A patient followed at a community-based clinic that is part of a large health care system with an in…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49724/psn-pdf
    January 01, 2015 - Bowel Injury After Laparoscopic Surgery January 1, 2015 Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery The Case A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mes…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33634/psn-pdf
    May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia May 1, 2006 Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia Perspective Over the last decade, sur…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49772/psn-pdf
    October 01, 2016 - Lapse in Antibiotics Leads to Sepsis October 1, 2016 Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis The Case A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal pain, fevers, and short…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33594/psn-pdf
    November 18, 2021 - Such a focus increases the probability that positive performance can be reinforced, and new ideas can
  10. psnet.ahrq.gov/web-mm/translating-normal-abnormal
    October 02, 2019 - suggests mixed results.( 7-10 ) As with domains outside medicine, the accuracy of machine translation increases
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49657/psn-pdf
    July 01, 2012 - through the use of simulation.(23) Extensive research documents that simulation-based procedure training increases
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73336/psn-pdf
    May 26, 2021 - Untreated syphilis increases the risk of HIV infection while ulcers are present as syphilitic ulcers
  13. psnet.ahrq.gov/perspective/equity-patient-safety
    September 24, 2024 - Annual Perspective Equity in Patient Safety Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD | March 27, 2024  View more articles from the same authors. Citation Text: Thomas A, Lee M, Mossburg S. Equity in Patient Safety. …
  14. psnet.ahrq.gov/web-mm/getting-root-matter
    September 01, 2005 - SPOTLIGHT CASE Getting to the Root of the Matter Citation Text: Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Schola…
  15. psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49483/psn-pdf
    June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…
  17. psnet.ahrq.gov/web-mm/insert-omission
    May 09, 2014 - The presence of an IUC increases the risk of spontaneous abortion nearly three-fold, so, whether a pregnancy … should be removed as soon as possible because the risk of spontaneous abortion in the presence of an IUC increases
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49503/psn-pdf
    February 01, 2006 - Nurses feel that they must respond to these interruptions and hassles (5), but doing so increases the … In addition to interruptions and hassles, another factor that increases the risks to patients is low
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49826/psn-pdf
    April 01, 2018 - The use of checklists in clinical environments increases adherence to protocols, reduces complications … The use of checklists in clinical environments increases adherence to protocols, reduces complications
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49473/psn-pdf
    March 01, 2005 - The tendency to take shortcuts and save time is a very human one, but it also increases the risk of … Lack of predictability greatly increases the risk of mistakes.

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