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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - to improve care
2. data monitoring
3. patient outcomes
4. evidence-based medicine
5. quality indicators
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psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
October 30, 2024 - Indicators of intensive care unit capacity strain: a systematic review. Crit Care. 2018;22(1):86.
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psnet.ahrq.gov/Information/Editor
May 23, 2025 - refine the function of several of the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - January 17, 2024
Validity of 16 AHRQ Patient Safety Indicators to identify in-hospital
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - The Dose Makes the Poison: Medication Error During
Procedural Sedation in the Pediatric Emergency
Department.
April 26, 2023
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the
Pediatric Emergency Department. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/do…
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - Missing Trauma
Citation Text:
Jurkovich GJ. Missing Trauma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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…
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psnet.ahrq.gov/web-mm/bleeding-risk
November 01, 2003 - Bleeding Risk
Citation Text:
Crowther MA. Bleeding Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - The Dropped Lung
Citation Text:
Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/node/49817/psn-pdf
January 01, 2018 - Slow Down: Right Drug, Wrong Formulation
January 1, 2018
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
The Case
A 65-year-old man presented to his primary care clinic for follow-up after a recent hospitaliz…
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - A Mistaken Dose of Naloxone?
December 18, 2019
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
The Case
A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up
appointment. He h…
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psnet.ahrq.gov/web-mm/suicidal-man-gun
May 01, 2005 - Suicidal Man With Gun
Citation Text:
Simon RI. Suicidal Man With Gun. 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/web-mm/premature-or-overdue
December 23, 2020 - Premature or Overdue?
Citation Text:
Thomas J, Hannah M. Premature or Overdue?. 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/web-mm/milliliters-vs-milligrams
September 01, 2004 - Milliliters vs. Milligrams
Citation Text:
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - The Second Victim Phenomenon: A Harsh Reality of
Health Care Professions
May 1, 2011
Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [internet].
2011.
https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
Perspective
The Instit…
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psnet.ahrq.gov/node/846127/psn-pdf
March 15, 2023 - Sepsis Resulting from Delays in Treatment and
Miscommunication among Specialists
March 15, 2023
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-
spec…
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psnet.ahrq.gov/node/49554/psn-pdf
January 01, 2008 - Chemotherapy Extravasation
January 1, 2008
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation
The Case
A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and
her oncologist decided to begin sys…
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psnet.ahrq.gov/node/49668/psn-pdf
October 01, 2012 - Buprenorphine and the Medically Ill Patient
October 1, 2012
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
The Case
A 60-year-old man with a 15-year history of oxycodone dependence presented to a substance …
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psnet.ahrq.gov/node/49489/psn-pdf
September 01, 2005 - Double Trouble
September 1, 2005
Gurwitz JH. Double Trouble. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/double-trouble
Case Objectives
Appreciate the incidence of adverse drug events in older persons
List preventative measures that can be used to minimize medication errors in this population
Encourage…
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psnet.ahrq.gov/node/49778/psn-pdf
December 01, 2016 - One Dose, Two Errors
December 1, 2016
Filice GA. One Dose, Two Errors. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/one-dose-two-errors
The Case
A 65-year-old woman was admitted to the intensive care unit (ICU) with severe sepsis and respiratory
failure secondary to community-acquired pneumonia. The pati…