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psnet.ahrq.gov/web-mm/urinary-retention-dilemma
March 01, 2013 - Urinary Retention Dilemma
Citation Text:
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
August 21, 2007 - SPOTLIGHT CASE
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
Citation Text:
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…
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psnet.ahrq.gov/node/49410/psn-pdf
July 01, 2003 - A Little Shuteye
July 1, 2003
Farion KJ. A Little Shuteye. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/little-shuteye
The Case
A 3-year-old boy was seen in urgent care for a superficial laceration above the left eyebrow. The
pediatrician had heard of the availability of topical skin adhesive that can be…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.131_slideshow.ppt
August 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case August 2006
Physical Diagnosis: A Lost Art?
Source and Credits
This presentation is based on the August 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: George Thompson III,…
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psnet.ahrq.gov/node/49425/psn-pdf
November 01, 2003 - Misread Label
November 1, 2003
Franklin BD. Misread Label. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/misread-label
The Case
An infant was born with sluggish respirations. During labor the infant’s mother had received meperidine
[Demerol, a pain medication], a narcotic with a half-life of 2.5-4.0 hours…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
November 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case November 2008
Dangerous Shift
Source and Credits
This presentation is based on the November 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Emily S. Patterson, PhD
Institute for Ergonomics, Ohi…
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psnet.ahrq.gov/node/33585/psn-pdf
March 15, 2025 - Radiation Safety
March 15, 2025
Radiation Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/radiation-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 2025…
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psnet.ahrq.gov/node/33781/psn-pdf
March 01, 2015 - In Conversation With… Brian Jarman, PhD
March 1, 2015
In Conversation With… Brian Jarman, PhD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
Editor's note: Sir Brian Jarman is an emeritus professor at Imperial College School of Medicine and a
past president of the Britis…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - System-related factors can be addressed on an institutional level through increased emphasis and training
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psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
May 19, 2021 - However, hospitals may choose to use nurses or case managers based on available resources and institutional
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psnet.ahrq.gov/web-mm/dropping-new-lows
December 18, 2024 - common barriers to implementation were insufficient of coordination among hospital team members, lack of institutional
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psnet.ahrq.gov/node/843051/psn-pdf
February 01, 2023 - A multi-institutional international study of risk factors for
hematoma after thyroidectomy.
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - Delayed Diagnosis of Gastric Perforation
March 15, 2023
Patient harm and institutional
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psnet.ahrq.gov/web-mm/privacy-or-safety
December 01, 2011 - system—is considered research, and the patient's prior consent is needed unless a Privacy Board or Institutional
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psnet.ahrq.gov/issue/could-it-happen-here-learning-other-organizations-safety-errors
February 17, 2017 - Newspaper/Magazine Article
Could it happen here? Learning from other organizations' safety errors.
Citation Text:
Conway JB. Could it happen here? Learning from other organizations' safety errors. Healthcare Executive. 2008;23(6):64, 66-67.
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psnet.ahrq.gov/issue/simple-strategies-avoid-medication-errors
April 22, 2017 - Commentary
Simple strategies to avoid medication errors.
Citation Text:
Jenkins RH, Vaida AJ. Simple strategies to avoid medication errors. Fam Pract Manag. 2007;14(2):41-47.
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psnet.ahrq.gov/issue/inpatient-notes-diagnostic-excellence-starts-incessant-watch
August 31, 2022 - Commentary
Inpatient notes: diagnostic excellence starts with an incessant watch.
Citation Text:
Dhaliwal G. Annals for Hospitalists Inpatient Notes - Diagnostic Excellence Starts With an Incessant Watch. Ann Intern Med. 2017;167(8):HO2-HO3. doi:10.7326/m17-2447.
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Form…
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psnet.ahrq.gov/issue/framework-high-performance-health-system-united-states
April 12, 2006 - Book/Report
Framework for a High Performance Health System for the United States.
Citation Text:
Framework for a High Performance Health System for the United States. Mongan JJ. New York, NY; The Commonwealth Fund: 2006.
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Save to your library…
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psnet.ahrq.gov/issue/coronavirus-commission-safety-and-quality-nursing-homes
May 26, 2021 - Book/Report
Coronavirus Commission for Safety and Quality in Nursing Homes.
Citation Text:
Coronavirus Commission for Safety and Quality in Nursing Homes. Centers for Medicare and Medicaid Services. McLean, VA: MITRE Corporation; September 2020.
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…
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psnet.ahrq.gov/issue/innovation-safety-and-safety-innovation
October 27, 2021 - Commentary
Innovation in safety, and safety in innovation.
Citation Text:
Eisenberg D, Wren SM. Innovation in safety, and safety in innovation. JAMA Surg. 2014;149(1):7-9. doi:10.1001/jamasurg.2013.5112.
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