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  1. psnet.ahrq.gov/
    March 25, 2025 - This website is up to date as of March 24, 2025. You will not be able to register for an account and will no longer be able to obtain Continuing Medical Education (CME), Maintenance of Certification (MOC), or Continuing Pharmacy Education (CPE) credits. We are not taking submissions for WebM&M cases, Innovations, Train…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33604/psn-pdf
    December 15, 2024 - Pharmacist's Role in Medication Safety December 15, 2024 The Pharmacist's Role in Medication Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current res…
  3. psnet.ahrq.gov/curated-library/opioid-stewardship
    December 15, 2024 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Opioid Stewardship  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: AHRQ Date Created: January 24, 2025 …
  4. psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
    November 01, 2006 - In Conversation With...Donald A. Norman, PhD November 1, 2006  Also Read an Essay Citation Text: In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.In Conversation With...Donald A. Norman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthca…
  5. psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
    August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE August 31, 2020  Also Read the Essay Citation Text: In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020.In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-…
  6. psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
    September 01, 2003 - SPOTLIGHT CASE Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough Citation Text: Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
  7. psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
    October 01, 2007 - In Conversation with...David Marx, JD October 1, 2007  Also Read an Essay Citation Text: In Conversation with..David Marx, JD. PSNet [internet]. 2007.In Conversation with...David Marx, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
  8. psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
    September 27, 2023 - SPOTLIGHT CASE Missed Opportunities for Suicide Risk Assessment Citation Text: Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation For…
  9. psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
    March 27, 2024 - SPOTLIGHT CASE Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head Citation Text: Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
  10. psnet.ahrq.gov/primer/maternal-safety
    January 10, 2024 - Maternal Safety Citation Text: Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
  11. psnet.ahrq.gov/perspective/safety-across-board
    August 31, 2020 - Safety Across The Board August 31, 2020  Also Read the Conversation View more articles from the same authors. Citation Text: Fitall E, Hall KK, Gale B. Safety Across The Board . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
  12. psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
    October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case Citation Text: Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …
  13. psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary …
  14. psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
    November 01, 2012 - Defensive Medicine: "Glowing" with Pain Citation Text: Sethi MK. Defensive Medicine: "Glowing" with Pain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49687/psn-pdf
    August 21, 2013 - Emergency Error August 21, 2013 Symons NRA. Emergency Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/emergency-error Case Objectives State that emergency surgery is high risk and has high mortality. Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865374/psn-pdf
    March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and Challenges March 27, 2024 Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges Introducti…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72618/psn-pdf
    December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care December 23, 2020 https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards- medical-decisions Summary Nudges are a change in the way choices ar…
  18. Psn-Pdf (pdf file)

    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 …
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49664/psn-pdf
    January 01, 2013 - Empty Handoff September 1, 2012 Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/empty-handoff The Case A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a leg wound. The patient's medical history included chronic…

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