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  1. psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
    May 28, 2020 - KH: When thinking about surveillance and indicators that potentially unsafe conditions exist, is there
  2. psnet.ahrq.gov/web-mm/coming-short
    May 20, 2020 - Coming Up Short Citation Text: Hochberg Z'ev. Coming Up Short. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49565/psn-pdf
    July 01, 2008 - Wrong Route for Nutrients July 1, 2008 Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/wrong-route-nutrients The Case An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6 months. He had lost weight and d…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50844/psn-pdf
    January 29, 2020 - Improving Patient Safety and Team Communication through Daily Huddles January 29, 2020 Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles Background Communicat…
  5. 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 …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74022/psn-pdf
    March 01, 2021 - The Role of Community Pharmacists in Patient Safety October 25, 2021 Luchen GG, Hall KK, Hough KR. The Role of Community Pharmacists in Patient Safety . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety What is a community pharmacy? Community pharmacies are somet…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73905/psn-pdf
    October 06, 2021 - Health Equity and Maternal Health October 6, 2021 Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/health-equity-and-maternal-health Redefining Maternal Safety Maternal safety refers to the safety of a person during pregnancy, childb…
  8. 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,…
  9. 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…
  10. 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…
  11. 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…
  12. 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 …
  13. 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…
  14. 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…
  15. 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. …
  16. 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…
  17. 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…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33854/psn-pdf
    March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety March 1, 2018 Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety Perspective Errors in hospitals remain a major cause of death.(1…
  19. 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…
  20. 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 …

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