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7701. Patient Engagement and Patient Safety | PSNet
      psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
      February 01, 2013 - Patient Engagement and Patient Safety Saul N. Weingart, MD, PhD | February 1, 2013  Also Read a Conversation View more articles from the same authors. Citation Text: Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. Rockville (MD): Agency fo…

7702. Building a Safety Program in a Vast Health Care Network | PSNet
      psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
      March 01, 2019 - Building a Safety Program in a Vast Health Care Network Paul E. Phrampus, MD | March 1, 2019  Also Read a Conversation View more articles from the same authors. Citation Text: Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet].…

7703. In Conversation With… Mary Dixon-Woods, DPhil | PSNet
      psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
      March 01, 2017 - In Conversation With… Mary Dixon-Woods, DPhil March 1, 2017  Also Read an Essay Citation Text: In Conversation With… Mary Dixon-Woods, DPhil. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

7704. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836877/psn-pdf
      May 16, 2022 - In Conversation With... Remle P. Crowe, PhD May 16, 2022 In Conversation With.. Remle P. Crowe, PhD . PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd Editor’s Note: Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional ro…

7705. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit | PSNet
      psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
      December 01, 2012 - Strong evidence suggests that increasing doses and duration of exposure raises the risk of delirium in

7706. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.227_slideshow.ppt
      November 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Treatment Challenges After Discharge * * Source and Credits This presentation is based on the November 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Chase Coffey, MD, Henry Ford Health System,…

7707. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33612/psn-pdf
      May 01, 2005 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience May 1, 2005 Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/organizat…

7708. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49800/psn-pdf
      July 01, 2017 - The Hidden Harms of Hand Sanitizer July 1, 2017 Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer The Case A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital for community-acquired pn…

7709. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49499/psn-pdf
      December 02, 2020 - An Outpatient 'Zebra' January 1, 2006 Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/outpatient-zebra The Case A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness. His past medical history included lumbar disc diseas…

7710. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.290_slideshow.ppt
      February 01, 2013 - Spotlight Case July 2008 Spotlight Case Delay in Treatment: Failure to Contact Patient Leads to Significant Complications * * Source and Credits This presentation is based on the February 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: …

7711. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
      May 01, 2011 - Spotlight Case July 2008 Spotlight Case Duty to Disclose Someone Else’s Error * * Source and Credits This presentation is based on the May 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Thomas H. Gallagher, MD University of Washington …

7712. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
      December 01, 2009 - Spotlight Case [MONTH] 2003 Spotlight Case Standard Deviations Source and Credits This presentation is based on the December 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James E. Sabin, MD Harvard Medical School; Harvard Pilgrim Heal…

7713. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
      February 01, 2018 - PowerPoint Presentation Spotlight Signout Fallout 1 Source and Credits This presentation is based on the February 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…

7714. CE/MOC Quizzes | PSNet
      psnet.ahrq.gov/cme
      February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations A man with a history of prior umbilical hernia repair presented to the emergency department (ED) with abdominal pain and was initially diagnosed with cholelithiasis before being discharged home. However, the next day he returned to …

7715. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33798/psn-pdf
      January 01, 2015 - Accountability in Patient Safety January 1, 2015 Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/accountability-patient-safety Annual Perspective 2015 The tension between the no-blame culture espoused in the early years of the safety movement and …

7716. Adverse Events, Near Misses, and Errors | PSNet
      psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
      March 30, 2022 - Adverse Events, Near Misses, and Errors Citation Text: Adverse Events, Near Misses, and Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

7717. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50858/psn-pdf
      January 31, 2020 - Artificial Intelligence and Diagnostic Errors January 31, 2020 Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors Definition of Artificial Intelligence The definition of artificial intelligence (…

7718. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33852/psn-pdf
      January 01, 2017 - Patient Engagement in Safety January 1, 2017 Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/patient-engagement-safety Annual Perspective 2017 Background In the past 2 decades, patient engagement in safety has evolved from obscurity to maturity. The Ins…

7719. Root Cause Analysis | PSNet
      psnet.ahrq.gov/primer/root-cause-analysis
      March 30, 2022 - Root Cause Analysis Citation Text: Root Cause Analysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

7720. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
      September 01, 2011 - Spotlight Case July 2008 Spotlight Case The Safety and Quality of Long Term Care * * Source and Credits This presentation is based on the September 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Amy A. Vogelsmeier, PhD, RN, GCNS-BC, Uni…