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3721. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49392/psn-pdf
      April 01, 2003 - Another Fall April 1, 2003 Bogardus SG. Another Fall. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/another-fall Case Objectives List risk factors for falls in hospitalized patients Understand appropriate use of restraints Identify system issues contributing to falls in hospitalized patients Case & Comm…

3722. In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO | PSNet
      psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
      January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO January 12, 2022  Also Read the Essay Citation Text: In Conversation With.…

3723. In Conversation With… Sharon K. Inouye, MD, MPH | PSNet
      psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
      December 01, 2012 - In Conversation With… Sharon K. Inouye, MD, MPH December 1, 2012  Also Read an Essay Citation Text: In Conversation With… Sharon K. Inouye, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…

3724. Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
      January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic January 12, 2022  Also Read the Conversation View more articles from the same authors. Citation Text: Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and…

3725. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49689/psn-pdf
      August 21, 2013 - Anesthesia: A Weighty Issue August 21, 2013 Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/anesthesia-weighty-issue The Case A 77-year-old woman was evaluated preoperatively in anticipation of an elective left hip arthroplasty. She reported having a history of hyperte…

3726. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50615/psn-pdf
      October 30, 2019 - Misidentifying the Unidentified – John Doe and the EHR October 30, 2019 Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr The Case  Two male patients of similar age arrived at the same …

3727. Spotlight Case September 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
      September 01, 2003 - Spotlight Case September 2003 Spotlight Case September 2003 Infant Paralyzed for Intubation Before Airway Materials Ready Source and Credits This presentation is based on the Sept. 2003 AHRQ WebM&M Spotlight Case in Pediatrics See the full article at http://webmm.ahrq.gov CME credit is available through the …

3728. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49421/psn-pdf
      October 01, 2003 - Urine a Tough Position October 1, 2003 Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/urine-tough-position The Case A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although she did not want to have a baby at that time, she sta…

3729. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49559/psn-pdf
      April 01, 2008 - The Forgotten Drip April 1, 2008 Josephson AS. The Forgotten Drip. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/forgotten-drip The Case A 45-year-old man was brought to the emergency department by his friends because of a 1-day history of a severe headache and "bizarre behavior." A computed tomography (C…

3730. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49509/psn-pdf
      April 01, 2006 - Insert Omission April 1, 2006 Darney P. Insert Omission. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/insert-omission The Case A multiparous woman presented to the gynecology clinic requesting intrauterine contraceptive (IUC) placement (Figure). She was appropriately counseled on the risks and benefits o…

3731. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
      December 01, 2011 - Spotlight Case July 2008 Spotlight Case Order Interrupted by Text: Multitasking Mishap * * Source and Credits This presentation is based on the December 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John Halamka, MD, MS, Chief Informa…

3732. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33794/psn-pdf
      November 01, 2015 - In Conversation With… Lorri Zipperer, MA November 1, 2015 In Conversation With… Lorri Zipperer, MA. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma Editor's note: Lorri Zipperer, principal at Zipperer Project Management, was a founding staff member of the National Patient…

3733. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49667/psn-pdf
      October 01, 2012 - Looking for Meds in All the Wrong Places October 1, 2012 Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places The Case A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She went to t…

3734. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
      June 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case June 2004 The Wrong Shot: Error Disclosure Source and Credits This presentation is based on the June 2004 AHRQ WebM&M Spotlight Case in Pediatrics CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Commentary by: Thomas H. …

3735. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33713/psn-pdf
      June 01, 2011 - The Safety of Medical Devices June 1, 2011 Nemeth CP. The Safety of Medical Devices. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/safety-medical-devices Perspective Edward Tenner is right. Technology does have reverberations, including unintended consequences, or "revenge effects."(1) While such dra…

3736. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
      November 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case November 2005 Reconciling Doses Source and Credits This presentation is based on the November 2005 Spotlight Case in Emergency Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Frank Federico, RPh,…

3737. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33757/psn-pdf
      October 01, 2013 - Safety in Radiology October 1, 2013 Pinto A. Safety in Radiology. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/safety-radiology Perspective The use of medical imaging to depict and to help diagnose illness and injury as well as to guide therapeutic interventions has expanded greatly during the past …

3738. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33753/psn-pdf
      August 22, 2013 - Update on Safety Culture August 22, 2013 Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/update-safety-culture Perspective Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians treat each other with r…

3739. Responding to Patient Safety Events | PSNet
      psnet.ahrq.gov/primer/responding-patient-safety-events
      October 18, 2023 - Responding to Patient Safety Events Citation Text: Shaikh U. Responding to Patient Safety Events. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

3740. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33606/psn-pdf
      December 15, 2024 - Opioid Safety December 15, 2024 Opioid Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/opioid-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in 2024. Bac…