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psnet.ahrq.gov/issue/iv-vincristine-survey-shows-safety-improvements-needed
March 14, 2023 - Newspaper/Magazine Article
IV vincristine survey shows safety improvements needed.
Citation Text:
IV vincristine survey shows safety improvements needed. ISMP Medication Safety Alert! Acute care edition. February 23, 2006.
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psnet.ahrq.gov/issue/discharge-missteps-can-send-seniors-back-hospital
March 28, 2012 - Newspaper/Magazine Article
Discharge missteps can send seniors back to hospital.
Citation Text:
Discharge missteps can send seniors back to hospital. Korc B, Landers SJ. American Medical News. February 15, 2010.
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psnet.ahrq.gov/issue/doctors-use-more-devices-potential-distraction-grows
March 06, 2005 - Newspaper/Magazine Article
As doctors use more devices, potential for distraction grows.
Citation Text:
As doctors use more devices, potential for distraction grows. Richtel M.
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psnet.ahrq.gov/issue/fire-safety
March 18, 2020 - Multi-use Website
Fire Safety.
Citation Text:
Fire Safety. Council on Surgical & Perioperative Safety.
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psnet.ahrq.gov/issue/knowledge-power-averting-safety-compromising-events-or
July 13, 2010 - Commentary
Knowledge is power: averting safety-compromising events in the OR.
Citation Text:
Catalano K. Knowledge is power: averting safety-compromising events in the OR. AORN J. 2008;88(6):987-95. doi:10.1016/j.aorn.2008.06.002.
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psnet.ahrq.gov/issue/safely-home-what-happens-when-people-leave-hospital-care-settings
August 02, 2023 - Book/Report
Safely Home: What Happens When People Leave Hospital Care Settings?
Citation Text:
Safely Home: What Happens When People Leave Hospital Care Settings? London, UK: Healthwatch England; July 2015.
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psnet.ahrq.gov/issue/whos-sorry-now
January 04, 2019 - Newspaper/Magazine Article
Who’s sorry now?
Citation Text:
Weber DO. Who's sorry now? Physician executive. 2006;32(2):6, 11-4.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
October 01, 2013 - PowerPoint Presentation
Spotlight Case
It's Sarah, not Stephen!
1
This presentation is based on the October 2013 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Urmimala Sarkar, MD, MPH, University of California at San Francisco
Editor, AHRQ WebM&…
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - Staggered Sensitivity Results
Citation Text:
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - Medication Reconciliation Pitfalls
Citation Text:
Weber RJ. Medication Reconciliation Pitfalls. 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/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/node/49476/psn-pdf
March 02, 2005 - Around the Block
March 1, 2005
Minichiello T. Around the Block. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/around-block
The Case
A 77-year-old woman with multiple medical problems was admitted to the hospital for an elective knee
replacement. The orthopedic surgeon, recognizing the risk of deep vein th…
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psnet.ahrq.gov/web-mm/or-peeping
May 01, 2015 - OR Peeping
Citation Text:
Mackenzie CF. OR Peeping. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.140_slideshow.ppt
December 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case December 2006
Hidden Heparins: HIT Happens
Source and Credits
This presentation is based on the December 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: Patrick F. Fogarty,…
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces
Hospitalizations Among Nursing Home Residents
July 28, 2021
https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-
home-residents
Summary
The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - PowerPoint Presentation
Spotlight
Errors in Sepsis Management
This presentation is based on the May 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF)
Editor, AHRQ WebM&M: Rober…
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psnet.ahrq.gov/node/851158/psn-pdf
June 28, 2023 - Ventricular Wall Injury during a Diagnostic Cardiac
Catheterization
June 28, 2023
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet].
2023.
https://psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
The Case
A patient was …
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - has predominantly referred to the culture and language of racial and ethnic minority groups, it is increasing
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/web-mm/triage-time-bomb
September 01, 2008 - ratios of waiting room patients to physicians and triage nurses were associated with longer waits.( 2 ) Increasing … World War I, the triage process emerged in hospitals in the late 1950s and early 1960s in response to increasing … Unfortunately, ambulance diversion may have a domino effect, increasing overcrowding at neighboring EDs