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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - A Stroke of Error
December 1, 2014
Barrett KM. A Stroke of Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/stroke-error
Case Objectives
State the key clinical factors to assess in a patient with suspected stroke.
Appreciate the relationship between elevated blood pressure and stroke in the acute sett…
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced
Respiratory Depression
May 27, 2020
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-
…
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - Spotlight
Hindsight is 20/20: Thrombolytics for Alcohol
Intoxication
Source and Credits
• This presentation is based on the April 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Eric Signoff, MD, Noelle Boctor, MD, and David K.
B…
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - WebM&M: Case Studies
WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…
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psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
May 26, 2021 - Endometriosis: A Common and Commonly Missed and Delayed Diagnosis
Citation Text:
Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Cit…
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement
Carole Stockmeier, Sarah Mossburg, Lee Merton | September 24, 2024
Also Read the Essay
View more articles from the same authors.
…
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - The Impact of Communication on Medication Errors
Citation Text:
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
Format:
…
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - AHRQ PSNet Webinar
AHRQ PSNet Webinar
Making Healthcare Safer (MHS) IV:
Rapid Response Systems and Opioid Stewardship
February 10, 2025
Agenda
2
• Logistics
• Introduction to the Making Healthcare Safer (MHS) IV Reports
• Report 1 – Rapid Response Systems
► Discussion
► PSNet Resources
• Report 2 – Opioi…
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psnet.ahrq.gov/node/74149/psn-pdf
January 07, 2022 - Multiple Missed Opportunities for Suicide Risk
Assessment in Emergency and Primary Care Settings
January 7, 2022
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and
Primary Care Settings. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/multiple-missed-opportu…
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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/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - SPOTLIGHT CASE
A Missed Bowel Perforation - the Importance of Diagnostic Reasoning
Citation Text:
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - Sleep Deprivation Leads to Medication Error During
Spinal Epidural Anesthesia
August 30, 2023
Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-…
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psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety
Robert M. Wachter, MD | September 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. Playing Well with Others: "Translocational Research" in…
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - Some Patients Can't Wait: Improving Timeliness of
Emergency Department Care
March 25, 2020
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
D…
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psnet.ahrq.gov/node/864867/psn-pdf
April 10, 2024 - Hindsight is 20/20: Thrombolytics for Alcohol Intoxication
April 10, 2024
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
Disclosure of Relevant Financial Relationships: As a provider accredited by th…
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psnet.ahrq.gov/node/853902/psn-pdf
September 27, 2023 - A Missed Bowel Perforation - the Importance of
Diagnostic Reasoning
September 27, 2023
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
Disclosure of …
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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - Primary Care and Patient Safety: Opportunities at the
Interface
September 28, 2022
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
Editor’s Not…
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - SPOTLIGHT CASE
A Stroke of Error
Citation Text:
Barrett KM. A Stroke of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia
Citation Text:
Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings
Citation Text:
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…