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psnet.ahrq.gov/node/37142/psn-pdf
August 29, 2007 - psnet.ahrq.gov/issue/patient-safety-canada-update
Using survey data as well as information on patient safety indicators
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psnet.ahrq.gov/node/33800/psn-pdf
January 01, 2015 - Computerized Provider Order Entry and Patient Safety
January 1, 2015
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patient Safety. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
Annual Perspective 2015
Computerized provider order entry…
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psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
March 01, 2005 - Are Two Insulin Pumps Better Than One?
Citation Text:
Cook CB. Are Two Insulin Pumps Better Than One?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - Refused Medication Error
Citation Text:
Foley M. Refused Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
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psnet.ahrq.gov/node/49818/psn-pdf
January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis
January 1, 2018
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
The Case
A 50-year-old man presented to a primary care clinic to establish care, as he ha…
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psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - Methicillin-Resistant Staphylococcus aureus
April 1, 2008
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
Perspective
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
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psnet.ahrq.gov/node/49835/psn-pdf
January 01, 2020 - Don't Pick the PICC
July 1, 2018
McGill RL. Don't Pick the PICC. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/dont-pick-picc
The Case
A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy;
glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
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psnet.ahrq.gov/node/33845/psn-pdf
November 01, 2017 - In Conversation With… Wanda Pratt, PhD
November 1, 2017
In Conversation With… Wanda Pratt, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
Editor's note: Wanda Pratt is a Professor in the Information School with an adjunct appointment in the
Division of Biomedical and …
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psnet.ahrq.gov/node/33762/psn-pdf
March 01, 2014 - In Conversation With… Alison Holmes, MD, MPH
March 1, 2014
In Conversation With… Alison Holmes, MD, MPH. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
Editor's note: Dr. Alison Holmes is Director of Infection Prevention and Control at Imperial College
Healthcare NHS …
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psnet.ahrq.gov/node/33699/psn-pdf
August 01, 2010 - Operationalizing Patient Safety at Academic Medical
Centers
August 1, 2010
Chakraborti C, Kahn MJ, Krane K. Operationalizing Patient Safety at Academic Medical Centers. PSNet
[internet]. 2010.
https://psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
Perspective
Academic medical…
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psnet.ahrq.gov/node/49739/psn-pdf
August 21, 2015 - Breathe Easy: Safe Tracheostomy Management
August 21, 2015
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
The Case
A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…
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psnet.ahrq.gov/node/49715/psn-pdf
August 21, 2014 - Liver Biopsy: Proceed With Caution
August 21, 2014
Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
The Case
A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast
cancer, presented t…
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psnet.ahrq.gov/node/836850/psn-pdf
March 31, 2022 - Annual Perspective: Topics in Medication Safety
March 31, 2022
Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
Introduction
Issues with medication management and errors in medi…
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - Complications of ECMO During Transport
Citation Text:
Broman M. Complications of ECMO During Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/issue/did-duty-hour-reform-lead-better-outcomes-among-highest-risk-patients
January 13, 2010 - 2014
Effects of resident duty hour reform on surgical and procedural patient safety indicators … 2010
Effects of resident duty hour reform on surgical and procedural patient safety indicators
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psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading
to Multiple Complications and Operations
September 25, 2024
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications
and Operations. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
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psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - Spotlight
Spotlight
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
1
Source and Credits
This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: David…
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psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - A Statewide Collaborative to Support Vaginal Birth and
Reduce Unnecessary Cesarean Deliveries
July 8, 2022
https://psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-
cesarean-deliveries
Summary
Started in response to rising maternal morbidity and mortality rates in …
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psnet.ahrq.gov/issue/2017-ismp-medication-safety-self-assessment-communityambulatory-pharmacy
June 07, 2017 - Measurement Tool/Indicator
2017 ISMP Medication Safety Self Assessment for Community/Ambulatory Pharmacy.
Citation Text:
2017 ISMP Medication Safety Self Assessment for Community/Ambulatory Pharmacy. Horsham, PA: Institute for Safe Medication Practices; 2017.
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…
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psnet.ahrq.gov/issue/wrong-patient-wrong-site-procedures-persist-despite-safety-protocol
April 24, 2013 - Newspaper/Magazine Article
Wrong-patient, wrong-site procedures persist despite safety protocol.
Citation Text:
Wrong-patient, wrong-site procedures persist despite safety protocol. O'Reilly KB.
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