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psnet.ahrq.gov/issue/medication-rounds-tool-promote-medication-safety-children-medical-complexity
February 12, 2020 - Commentary
Medication rounds: a tool to promote medication safety for children with medical complexity.
Citation Text:
Rojas CR, Moore A, Coffin A, et al. Medication rounds: a tool to promote medication safety for children with medical complexity. Jt Comm J Qual Patient Saf. 2023;49(4):2…
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psnet.ahrq.gov/issue/world-federation-chiropractic-global-patient-safety-task-force-call-action
December 23, 2020 - Review
The World Federation of Chiropractic Global Patient Safety Task Force: a call to action.
Citation Text:
Coleman BC, Rubinstein SM, Salsbury SA, et al. The World Federation of Chiropractic Global Patient Safety Task Force: a call to action. Chiropr Man Therap. 2024;32(1):15. doi:10…
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psnet.ahrq.gov/issue/challenges-and-opportunities-shared-decision-making-highlighted-covid-19
June 15, 2022 - Commentary
The challenges and opportunities for shared decision making highlighted by COVID-19.
Citation Text:
Abrams EM, Shaker M, Oppenheimer J, et al. The challenges and opportunities for shared decision making highlighted by COVID-19. J Allergy Clin Immunol Pract. 2020;8(8):2474-2480…
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psnet.ahrq.gov/issue/sustaining-and-spreading-reduction-adverse-drug-events-multicenter-collaborative
November 16, 2022 - Study
Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative.
Citation Text:
Tham E, Calmes HM, Poppy A, et al. Sustaining and spreading the reduction of adverse drug events in a multicenter collaborative. Pediatrics. 2011;128(2):e438-45. doi:10.1542…
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psnet.ahrq.gov/issue/assessment-impact-just-culture-quality-and-safety-us-hospitals
April 13, 2017 - Study
Emerging Classic
An assessment of the impact of just culture on quality and safety in US hospitals.
Citation Text:
Edwards MT. An Assessment of the Impact of Just Culture on Quality and Safety in US Hospitals. Am J Med Qual. 2018;33(5):502-508. doi:10.1177…
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psnet.ahrq.gov/issue/graduate-medical-education-and-patient-safety-busy-and-occasionally-hazardous-intersection
March 02, 2011 - Commentary
Classic
Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.
Citation Text:
Shojania KG, Fletcher KE, Saint S. Graduate medical education and patient safety: a busy--and occasionally hazardous--intersectio…
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psnet.ahrq.gov/issue/bracing-storm-one-health-care-systems-planning-covid-19-surge
July 22, 2020 - Commentary
Bracing for the storm: one health care system's planning for the COVID-19 surge.
Citation Text:
Kim CS, Meo N, Little D, et al. Bracing for the storm: one health care system's planning for the COVID-19 surge. Jt Comm J Qual Patient Saf. 2021;47(1):60-68. doi:10.1016/j.jcjq.202…
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psnet.ahrq.gov/issue/long-term-care-nurses-experiences-patient-safety-incident-management-qualitative-study
March 24, 2021 - Study
Long-term care nurses' experiences with patient safety incident management: a qualitative study.
Citation Text:
Serre N, Espin S, Indar A, et al. Long-term care nurses' experiences with patient safety incident management: a qualitative study. J Nurs Care Qual. 2022;37(2):188-194. d…
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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - Dual Therapy Debacle
Citation Text:
Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/49695/psn-pdf
October 01, 2013 - Finding Fault With the Default Alert
October 1, 2013
Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/finding-fault-default-alert
The Case
A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital
after experiencing …
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psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
September 26, 2012 - Amended Lab Results: Communication Slip
Citation Text:
Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/node/33773/psn-pdf
September 01, 2014 - Overuse as a Patient Safety Problem
September 1, 2014
Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem
Perspective
Nearly half of primary care physicians in the United States believe that patients cared for in their own
prac…
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psnet.ahrq.gov/web-mm/security-lapse
December 18, 2019 - Security Lapse
Citation Text:
Mason D. Security Lapse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Shake Well
Citation Text:
Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downloa…
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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Did We Forget Something?
September 1, 2003
Gibbs VC. Did We Forget Something? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/did-we-forget-something
The Case
A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially
attributed to ventilator-associated pneumo…
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - Spotlight Case July 2008
Spotlight Case
All in the History
Source and Credits
This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Christopher Fee, MD, University of California, San Francisco
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
May 01, 2006 - Spotlight Case
Spotlight Case May 2006
Right? Left? Neither!
Source and Credits
This presentation is based on the May 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
January 01, 2020 - PowerPoint Presentation
Spotlight
A ʺReflexiveʺ Diagnosis in Primary Care
1
This presentation is based on the April 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John Betjemann, MD, and S. Andrew Josephson, MD, University of California, San…
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psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - "Superficial" Report Leads to "Deep" Problem
December 1, 2009
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
The Case
A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…