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psnet.ahrq.gov/web-mm/misread-label
August 28, 2024 - Misread Label
Citation Text:
Franklin BD. Misread Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
May 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Perils of Cross Coverage
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Source and Credits
This presentation is based on the May 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …
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psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - Wrong-Time Error With High-Alert Medication
September 1, 2016
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
The Case
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Strategies to Improve Organizational Health Literacy.
May 31, 2023
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
Background
Health literacy is important at both the personal …
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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - Interpreting the Patient Safety Literature
Kaveh G. Shojania, MD | June 1, 2005
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Citation Text:
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - Do Not Miss Sepsis Needles in Viral Haystacks!
March 27, 2024
Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accredit…
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - The Safety of Medical Devices
Christopher Nemeth, PhD | June 1, 2011
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Citation Text:
Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health
Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for
Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
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psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
October 01, 2007 - Making Just Culture a Reality: One Organization's Approach
Alison H. Page, MS, MHA | October 1, 2007
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View more articles from the same authors.
Citation Text:
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [in…
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psnet.ahrq.gov/node/60363/psn-pdf
March 01, 2021 - Transition Coaches® Reduce Readmissions for Medicare
Patients With Complex Postdischarge Needs
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-
postdischarge-needs
Summary
Under a program kn…
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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - SPOTLIGHT CASE
Do Not Miss Sepsis Needles in Viral Haystacks!
Citation Text:
Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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For…
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psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
May 01, 2009 - Patient Safety: A Perspective from Office Practice
Richard J. Baron, MD | May 1, 2009
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Citation Text:
Baron RJ. Patient Safety: A Perspective from Office Practice. PSNet [internet]. Rockville (MD…
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psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety
Ronen Rozenblum, MD, MPH, and David Bates, MD, MS | November 1, 2017
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Citation Text:
Rozenblum R, Bates DW. The Role…
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psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
August 22, 2014 - areas must be explored: diagnostic errors, the role of patients in improving safety, leveraging EHRs in increasing
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psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
August 01, 2014 - areas must be explored: diagnostic errors, the role of patients in improving safety, leveraging EHRs in increasing
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psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - One ACE Too Many
Citation Text:
Juurlink DN. One ACE Too Many. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/60167/psn-pdf
April 12, 2024 - Discharge Planning and Transitions of Care
March 25, 2020
Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
Background
Transitions of care refer to the movement of patients between different healthcare se…
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psnet.ahrq.gov/node/60746/psn-pdf
July 29, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy
July 29, 2020
Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
The Case
A 28-year-old woman arrived at the Emergency Department (ED) complaining o…
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psnet.ahrq.gov/node/853981/psn-pdf
September 27, 2023 - Walking Out of a Hospital After Attempted Suicide
September 27, 2023
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
The Case
A 42-year-old man with history of posttraumatic stress disorder …
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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - Cups of Error
Citation Text:
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…