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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
    October 01, 2013 - PowerPoint Presentation Spotlight Case It's Sarah, not Stephen! 1 This presentation is based on the October 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Urmimala Sarkar, MD, MPH, University of California at San Francisco Editor, AHRQ WebM&…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49632/psn-pdf
    July 01, 2011 - A Seasonal Care Transition Failure July 1, 2011 Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure The Case A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine resident—for routine follow-up…
  3. psnet.ahrq.gov/web-mm/staggered-sensitivity-results
    May 01, 2013 - Staggered Sensitivity Results Citation Text: Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
  4. psnet.ahrq.gov/web-mm/troubling-amine
    September 01, 2003 - A Troubling Amine Citation Text: Flynn EA. A Troubling Amine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  5. psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
    March 01, 2005 - Are Two Insulin Pumps Better Than One? Citation Text: Cook CB. Are Two Insulin Pumps Better Than One?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndN…
  6. psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
    February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3 Citation Text: Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73335/psn-pdf
    May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition Error May 26, 2021 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error The Case A 4-year-old (former 33-week premature) boy with a …
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
    January 01, 2008 - Spotlight Case [MONTH] 2003 Spotlight Case January 2008 How Do Providers Recover from Errors? Source and Credits This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Colin P. West, MD, PhD, Mayo Clini…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33632/psn-pdf
    April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD (hon) April 1, 2006 In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background and how…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33682/psn-pdf
    April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH April 1, 2009 In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph Editor's note: Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent s…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73999/psn-pdf
    October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49815/psn-pdf
    December 01, 2017 - Over-the-Counter Oversight December 1, 2017 Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/over-counter-oversight The Case A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although portions of his skin we…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49718/psn-pdf
    January 01, 2015 - Too Much, Too Fast September 1, 2014 Tuot D. Too Much, Too Fast. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/too-much-too-fast The Case A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for fever, tachycardia, and increased respiratory secretions. H…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49739/psn-pdf
    August 21, 2015 - Breathe Easy: Safe Tracheostomy Management August 21, 2015 Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management The Case A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumo…
  15. psnet.ahrq.gov/primer/patient-safety-101
    January 16, 2025 - Patient Safety 101 Citation Text: Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS D…
  16. psnet.ahrq.gov/web-mm/easily-forgotten-tube
    June 01, 2016 - An Easily Forgotten Tube Citation Text: Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863650/psn-pdf
    February 28, 2024 - Implementation and Sustainability of the ICU Liberation Bundle,” which may have garnered interest among other institutions
  18. psnet.ahrq.gov/web-mm/who-nose-where-airway
    May 01, 2016 - large studies, the sensitivities of these counts are only 35%-77%.( 10,11 ) Radiography is used in some institutions
  19. psnet.ahrq.gov/web-mm/silent-pain-neck
    August 19, 2020 - Monitoring Specific protocols for monitoring patients after neck surgery vary across institutions.
  20. psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
    November 01, 2023 - preoperative evaluation clinics have been associated with a reduction in in-hospital mortality at several institutions

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