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psnet.ahrq.gov/node/49545/psn-pdf
September 01, 2007 - Coming Undone: Failure of Closure Device
September 1, 2007
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
The Case
A 65-year-old man underwent coronary angiography because of atypical exertional chest…
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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/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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psnet.ahrq.gov/web-mm/preventable-rash
October 01, 2012 - Preventable Rash
Citation Text:
McLean C. Preventable Rash. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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…
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psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
July 01, 2017 - Shortcuts to Acetaminophen-induced Liver Failure
Citation Text:
Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - Harm From Alarm Fatigue
December 1, 2015
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue
Case Objectives
Define alarm fatigue and describe potential errors that can occur due to alarm fatigue.
Identify federal and national agencies focusing on …
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psnet.ahrq.gov/node/72834/psn-pdf
March 10, 2021 - Approach to Improving Patient Safety: Communication
March 10, 2021
Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet
[internet]. 2021.
https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
Introduction
Each one of the countless necessa…
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psnet.ahrq.gov/web-mm/environmental-safety-or
May 19, 2015 - Environmental Safety in the OR
Citation Text:
Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/inflicting-confusion
August 04, 2021 - Inflicting Confusion
Citation Text:
Scott FI, Lichtenstein GR. Inflicting Confusion. 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/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Emerging Safety Issues in Artificial Intelligence
Robert Challen, MA, MBBS | July 1, 2019
View more articles from the same authors.
Citation Text:
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
December 01, 2005 - An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up
Robert M. Wachter, MD | June 1, 2012
View more articles from the same authors.
Citation Text:
Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. …
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - When the Meds Don’t Reach the Bed
August 26, 2020
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
The Case
A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of
chronic obs…
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - SPOTLIGHT CASE
A Loss of Trust and a Missed Diagnosis
Citation Text:
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced
Respiratory Depression
May 27, 2020
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-
…
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psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - A Loss of Trust and a Missed Diagnosis
February 23, 2022
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counci…
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psnet.ahrq.gov/perspective/conversation-elizabeth-salisbury-afshar-about-harm-reduction-strategies-improve-safety
October 30, 2024 - In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024
Also Read the Essay
View more articles from the same auth…
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psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
October 30, 2024 - Harm Reduction Strategies to Improve Safety for People Who Use Substances
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Salisbury-…
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psnet.ahrq.gov/innovation/generalizability-medication-administration-discrepancy-detection-system-quantitative
November 04, 2020 - EMERGING INNOVATIONS
The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis
Citation Text:
Kirkendall E, Huth H, Rauenbuehler B, et al. The generalizability of a medication administration discrepancy detection system: quantitative compar…
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psnet.ahrq.gov/periodic-issue/periodic-issue-302
July 28, 2021 - July 28, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/periodic-issue/periodic-issue-353
August 05, 2022 - August 3, 2022 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…