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psnet.ahrq.gov/node/49496/psn-pdf
December 01, 2005 - Discharged Blindly
December 1, 2005
Iezzoni LI. Discharged Blindly. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharged-blindly
The Case
An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to
receive enoxaparin (Lovenox) for self-administration at home…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
March 01, 2013 - Spotlight Case July 2008
Spotlight Case
A Weighty Mistake
*
*
Source and Credits
This presentation is based on the March 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Seth J. Bokser, MD, MPH, Associate Professor of Pediatrics & Medical…
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - Accountability in Patient Safety
January 1, 2015
Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/accountability-patient-safety
Annual Perspective 2015
The tension between the no-blame culture espoused in the early years of the safety movement and …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
February 01, 2018 - PowerPoint Presentation
Spotlight
Signout Fallout
1
Source and Credits
This presentation is based on the February 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…
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psnet.ahrq.gov/primer/leadership-role-improving-safety
September 15, 2024 - Leadership Role in Improving Safety
Citation Text:
Leadership Role in Improving Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
April 27, 2022 - Readmissions and Adverse Events After Discharge
Citation Text:
Readmissions and Adverse Events After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/primer/diagnostic-errors
June 15, 2024 - Diagnostic Errors
Citation Text:
Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/node/33570/psn-pdf
June 15, 2024 - Diagnostic Errors
June 15, 2024
Diagnostic Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/diagnostic-errors
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 20…
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - Missed Nursing Care
June 15, 2024
Missed Nursing Care. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/missed-nursing-care
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…
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psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
February 01, 2010 - is being driven by the American Association of Medical Colleges (AAMC) in their Integrating Quality initiative
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psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
February 01, 2010 - is being driven by the American Association of Medical Colleges (AAMC) in their Integrating Quality initiative
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - SEIPS: Systems Engineering Initiative for Patient Safety.
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psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
February 01, 2012 - The concept of graduated levels of independence and responsibility form the basis of a new initiative
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - September 28, 2011
A system-wide initiative to prevent retained vaginal sponges.
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format: …
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psnet.ahrq.gov/node/866578/psn-pdf
August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of
Subtherapeutic Insulin Therapy
August 28, 2024
Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…
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psnet.ahrq.gov/node/865884/psn-pdf
May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening
Complications after Gastric Bypass Surgery.
May 29, 2024
Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…
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psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - SPOTLIGHT CASE
"The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety
Citation Text:
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - SPOTLIGHT CASE
Right Regimen, Wrong Cancer: Patient Catches Medical Error
Citation Text:
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
September 09, 2013 - SPOTLIGHT CASE
Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care
Citation Text:
Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…