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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74022/psn-pdf
    March 01, 2021 - The Role of Community Pharmacists in Patient Safety October 25, 2021 Luchen GG, Hall KK, Hough KR. The Role of Community Pharmacists in Patient Safety . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety What is a community pharmacy? Community pharmacies are somet…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867804/psn-pdf
    February 26, 2025 - Are We Safer Today? February 26, 2025 Bates DW, Lee M, Mossburg SE. Are We Safer Today? PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/are-we-safer-today In the 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (now the National Academy of Medicine) drew on two lar…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49667/psn-pdf
    October 01, 2012 - Looking for Meds in All the Wrong Places October 1, 2012 Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places The Case A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She went to t…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33780/psn-pdf
    July 01, 2015 - Safety and Medical Education January 1, 2014 Ranji SR. Safety and Medical Education. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/safety-and-medical-education Annual Perspective 2014 As the patient safety field has grown, so too has the appreciation for the need to improve safety in medical educatio…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33636/psn-pdf
    July 01, 2006 - Key Issues in Developing a Successful Hospital Safety Program July 1, 2006 Whittington JC. Key Issues in Developing a Successful Hospital Safety Program. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program Perspective What are the key success factors…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49524/psn-pdf
    November 01, 2006 - Secured But Not Always Safe November 1, 2006 Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/secured-not-always-safe The Case An 84-year-old healthy woman underwent an elective left total knee replacement for degenerative osteoarthritis. She received spinal …
  7. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
    July 01, 2011 - Spotlight Case July 2008 Spotlight Case Watch the Warfarin! 1 2 Source and Credits This presentation is based on the July 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Raman Khanna, MD, and Margaret Fang, MD, MPH; University of California, Sa…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49460/psn-pdf
    September 01, 2004 - Security Lapse September 1, 2004 Mason D. Security Lapse. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/security-lapse The Case A medical student learned that the hospital's radiology image library was accessible throughout the university's computer system, meaning that patient x-rays could be viewed in d…
  9. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.257_slideshow.ppt
    December 01, 2011 - Spotlight Case July 2008 Spotlight Case Order Interrupted by Text: Multitasking Mishap * * Source and Credits This presentation is based on the December 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John Halamka, MD, MS, Chief Informa…
  10. 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,…
  11. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
    May 01, 2009 - Spotlight Case July 2008 Spotlight Case Delirium or Dementia? Source and Credits This presentation is based on the May 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: James L. Rudolph, MD, SM Editor, AHRQ WebM&M: Robert Wachter, MD Sp…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49559/psn-pdf
    April 01, 2008 - The Forgotten Drip April 1, 2008 Josephson AS. The Forgotten Drip. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/forgotten-drip The Case A 45-year-old man was brought to the emergency department by his friends because of a 1-day history of a severe headache and "bizarre behavior." A computed tomography (C…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33757/psn-pdf
    October 01, 2013 - Safety in Radiology October 1, 2013 Pinto A. Safety in Radiology. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/safety-radiology Perspective The use of medical imaging to depict and to help diagnose illness and injury as well as to guide therapeutic interventions has expanded greatly during the past …
  14. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
    November 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case November 2005 Reconciling Doses Source and Credits This presentation is based on the November 2005 Spotlight Case in Emergency Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Frank Federico, RPh,…
  15. Psn-Pdf (pdf file)

    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…
  16. psnet.ahrq.gov/primer/reporting-patient-safety-events
    March 30, 2022 - Reporting Patient Safety Events Citation Text: Reporting Patient Safety Events. 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 tagge…
  17. psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
    March 30, 2022 - Adverse Events, Near Misses, and Errors Citation Text: Adverse Events, Near Misses, and Errors. 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 X…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50699/psn-pdf
    November 26, 2019 - Patient Safety in Frail Older Patients November 26, 2019 Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients Background Older patients are at a particular risk of experiencing a patient safety event. Stud…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867004/psn-pdf
    October 30, 2024 - Critical Radiology Alert Process October 30, 2024 https://psnet.ahrq.gov/innovation/critical-radiology-alert-process Summary Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of unrelated abnormal findings and provides a companion follow-up process, with the goal o…
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
    June 01, 2003 - PowerPoint Presentation Spotlight Case June 2003 Missed Appendicitis webmm.ahrq.gov Source and Credits This presentation is based on June 2003 AHRQ WebM&M Spotlight Case in Surgery See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: James Adams, MD, Fei…

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