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psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis
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psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
May 01, 2019 - Liver Failure After Chemotherapy: Did We Forget Something?
Citation Text:
Lubel J. Liver Failure After Chemotherapy: Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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G…
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - On the Other Hand
Citation Text:
Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - CVC Removal: A Procedure Like Any Other
Citation Text:
Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - After-Visit Confusion
Citation Text:
Ventres W. After-Visit Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/49869/psn-pdf
July 02, 2019 - Failure to Rescue the Mother
July 2, 2019
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/failure-rescue-mother
The Case
A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal
bleeding. An …
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - PowerPoint Presentation
Spotlight
Diagnostic Delay in the Emergency Department
1
Source and Credits
This presentation is based on the May 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…
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psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
March 25, 2020 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules
Citation Text:
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. 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/poorly-advanced-directives
August 01, 2018 - Poorly Advanced Directives
Citation Text:
Anderson WG. Poorly Advanced Directives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - Don't Push
Citation Text:
Meltzer HY. Don't Push. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Downl…
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psnet.ahrq.gov/node/33645/psn-pdf
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and
Umpires Have in Common?
February 1, 2007
Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
Perspectiv…
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psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
January 07, 2015 - Haste Makes Care Unsafe
Citation Text:
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49594/psn-pdf
December 01, 2009 - Standard Deviations
December 1, 2009
Sabin JE. Standard Deviations. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/standard-deviations
Case Objectives
Understand the safety risks associated with patients being discharged against medical advice
(AMA).
Recognize safety risks associated with being part of a …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
June 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case June 2007
Beeline to Spine
Source and Credits
This presentation is based on June 2007
AHRQ WebM&M Spotlight Case
See full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Gerald W. Smetana, MD, Harvard Medical School, Beth Israel D…
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - Failed Interpretation of Screening Tool: Delayed
Treatment
September 1, 2017
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
The Case
An 88-year-old man present…
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psnet.ahrq.gov/node/33724/psn-pdf
February 01, 2012 - In Conversation With… Lawrence Smith, MD
February 1, 2012
In Conversation With… Lawrence Smith, MD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
Editor's note: Lawrence G. Smith, MD, is the founding Dean of Hofstra North Shore-LIJ School of
Medicine and Executive Vice P…
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psnet.ahrq.gov/node/49848/psn-pdf
January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble
November 1, 2018
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
The Case
Case #1:
A 34-year-old woman was scheduled for a hysteroscopy under g…
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psnet.ahrq.gov/node/33683/psn-pdf
April 01, 2009 - Accreditation and Regulation: Can They Help Improve
Patient Safety?
April 1, 2009
Warburton RN. Accreditation and Regulation: Can They Help Improve Patient Safety? PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
Perspective
My grandfath…
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psnet.ahrq.gov/web-mm/wrong-turn-through-colon-misplaced-peg
May 01, 2017 - Wrong Turn through Colon: Misplaced PEG
Citation Text:
Sorokin R, Conn M. Wrong Turn through Colon: Misplaced PEG. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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