-
psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - hopefully they will go to the hospital and put some pressure on them to elevate the
priority of safety initiatives
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psnet.ahrq.gov/node/74021/psn-pdf
October 25, 2021 - In this role, she leads initiatives related to community
pharmacy practitioners and their impact throughout
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - other interventions , including prescription drug monitoring programs (PDMPs) and prescriber education initiatives
-
psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
…
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psnet.ahrq.gov/node/865570/psn-pdf
April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program:
Applying a Proactive Approach With Data Review &
Collaborating With a Second Practitioner
April 10, 2024
https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-
approach-data
Summary
North American Partners…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
April 01, 2015 - PowerPoint Presentation
Spotlight
Dissecting the Presentation
*
This presentation is based on the April 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shirley Beng Suat Ooi, MBBS (S'pore), Emergency Medicine Department, National Univers…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
April 01, 2008 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
View more articles from the same authors.
Citation Text:
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. Rockville (MD): Agency for Healthcare Resea…
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psnet.ahrq.gov/node/865418/psn-pdf
March 27, 2024 - Cybersecurity and How to Maintain Patient Safety
March 27, 2024
Pelletreau B, Riggi J, Gale B, et al. Cybersecurity and How to Maintain Patient Safety. PSNet [internet].
2024.
https://psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
Introduction
The integration of information technology (I…
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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - Spotlight
Spotlight
The Consequences of Miscommunication
Regarding a Possible Artifact
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kriti Gwal, MD
o AHRQ WebM&M Edit…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
September 01, 2006 - Spotlight Case September 2006
Spotlight Case September 2006
Triple Handoff
Source and Credits
This presentation is based on the September 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: Arpana Vidyarthi, MD, UCSF Sc…
-
psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
-
psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…
-
psnet.ahrq.gov/node/49596/psn-pdf
December 01, 2009 - Round-Trip Service
December 1, 2009
McGrath MH. Round-Trip Service. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/round-trip-service
The Case
A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms
in his left knee. He was referred by his primary care provid…
-
psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…
-
psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
-
psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
Discharged with IV antibiotics:
When issues arise, who manages
the complications?
Source and Credits
• This presentation is based on the February 2020 AHRQ
WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Monica Donnel…
-
psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - Wrong Route for Nutrients
Citation Text:
Scott-Cawiezell JR. Wrong Route for Nutrients. 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 Endno…
-
psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity
Simulation
March 1, 2006
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
Point–Counterpoint
Editor's Note…