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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
    May 01, 2017 - PowerPoint Presentation Spotlight Diagnostic Delay in the Emergency Department 1 Source and Credits This presentation is based on the May 2017 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…
  2. psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
    September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization Citation Text: Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49545/psn-pdf
    September 01, 2007 - Coming Undone: Failure of Closure Device September 1, 2007 Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device The Case A 65-year-old man underwent coronary angiography because of atypical exertional chest…
  4. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
    June 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfer Troubles 1 2 Source and Credits This presentation is based on the June 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49461/psn-pdf
    September 01, 2004 - Reaction to Dye September 1, 2004 Cohan R. Reaction to Dye. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/reaction-dye The Case A patient was referred to urology after having several episodes of gross hematuria. The urologist thought that the patient might have a renal mass and sent him to radiology for a…
  6. psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
    September 01, 2006 - Is it possible to provide effective, safe care, and to do so without increasing costs even more? … These efforts include increasing disclosure of adverse events; root cause analyses; and programs for
  7. psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
    July 30, 2020 - of the Delta variant, the Omicron variant, and other variants of concern (VOCs) has resulted in an increasing
  8. psnet.ahrq.gov/issue/evaluation-interprofessional-team-training-program-improve-use-patient-safety-strategies
    May 18, 2022 - Study Evaluation of an interprofessional team training program to improve the use of patient safety strategies among healthcare professions students. Citation Text: Evaluation of an interprofessional team training program to improve the use of patient safety strategies among healthcare p…
  9. psnet.ahrq.gov/issue/medical-and-nursing-staff-highly-value-clinical-pharmacists-emergency-department
    September 09, 2008 - Study Medical and nursing staff highly value clinical pharmacists in the emergency department. Citation Text: Fairbanks RJ, Hildebrand JM, Kolstee KE, et al. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emergency Medicine Journal. 2007;24(10)…
  10. psnet.ahrq.gov/issue/medical-error-and-human-factors-engineering-where-are-we-now
    August 04, 2021 - Review Medical error and human factors engineering: where are we now? Citation Text: Gawron VJ, Drury CG, Fairbanks RJ, et al. Medical error and human factors engineering: where are we now? Am J Med Qual. 2006;21(1):57-67. Copy Citation Format: Google Scholar PubMed BibTe…
  11. psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost
    April 30, 2014 - Commentary Obstetric practice guidelines: labor's love lost? Citation Text: Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med. 2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474. Copy Citation Format: DOI Google Schola…
  12. psnet.ahrq.gov/issue/development-high-value-care-culture-survey-modified-delphi-process-and-psychometric
    December 22, 2018 - Study Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation. Citation Text: Gupta R, Moriates C, Harrison JD, et al. Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation. BMJ Qual Saf. 2017…
  13. psnet.ahrq.gov/issue/teamwork-healthcare-key-discoveries-enabling-safer-high-quality-care
    July 02, 2014 - Review Classic Teamwork in healthcare: key discoveries enabling safer, high-quality care. Citation Text: Rosen MA, DiazGranados D, Dietz AS, et al. Teamwork in healthcare: Key discoveries enabling safer, high-quality care. Am Psychol. 2018;73(4):433-450. doi:10.…
  14. psnet.ahrq.gov/issue/do-no-harm-and-most-good-ai-health-care
    March 19, 2019 - Commentary To do no harm - and the most good - with AI in health care. Citation Text: Goldberg CB, Adams L, Blumenthal D, et al. To do no harm - and the most good - with AI in health care. NEJM AI. 2024;1(3). doi:10.1056/aip2400036. Copy Citation Format: DOI Google Scholar …
  15. psnet.ahrq.gov/issue/textbook-rapid-response-systems-concept-and-implementation
    September 30, 2010 - Book/Report Textbook of Rapid Response Systems: Concept and Implementation. Citation Text: Textbook Of Rapid Response Systems: Concept And Implementation. (DeVita MA, ed.). Springer; 2025. ISBN 9783031679513. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…
  16. psnet.ahrq.gov/issue/digital-health-technology-specific-risks-medical-malpractice-liability
    January 18, 2023 - Commentary Digital health technology-specific risks for medical malpractice liability. Citation Text: Rowland SP, Fitzgerald JE, Lungren M, et al. Digital health technology-specific risks for medical malpractice liability. NPJ Digit Med. 2022;5(1):157. doi:10.1038/s41746-022-00698-3. C…
  17. psnet.ahrq.gov/issue/factors-associated-diagnostic-error-analysis-closed-medical-malpractice-claims
    July 13, 2022 - Study Factors associated with diagnostic error: an analysis of closed medical malpractice claims. Citation Text: Grenon V, Szymonifka J, Adler-Milstein J, et al. Factors associated with diagnostic error: an analysis of closed medical malpractice claims. J Patient Saf. 2023;19(3):211-215.…
  18. psnet.ahrq.gov/issue/why-diagnostic-errors-dont-get-any-respect-and-what-can-be-done-about-them
    February 10, 2015 - Commentary Why diagnostic errors don't get any respect--and what can be done about them. Citation Text: Wachter RM. Why Diagnostic Errors Don’t Get Any Respect—And What Can Be Done About Them. Health Aff (Millwood). 2010;29(9):1605-1610. doi:10.1377/hlthaff.2009.0513. Copy Citation …
  19. psnet.ahrq.gov/issue/guide-patient-and-family-engagement-hospital-quality-and-safety
    December 24, 2008 - Multi-use Website Guide to Patient and Family Engagement in Hospital Quality and Safety. Citation Text: Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD: Agency for Healthcare Research and Quality; June 2013. Copy Citation Save …
  20. psnet.ahrq.gov/issue/patients-role-patient-safety
    May 01, 2024 - Review The patient's role in patient safety. Citation Text: Corina I, Abram M, Halperin D. The patient's role in patient safety. Obstet Gynecol Clin North Am. 2019;46(2):215-225. doi:10.1016/j.ogc.2019.01.004. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML E…

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