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psnet.ahrq.gov/node/836878/psn-pdf
April 27, 2022 - The Media’s Role in Patient Safety
April 27, 2022
Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/medias-role-patient-safety
Brief History of the Media Influencing Patient Safety
Despite studies raising questions about avoidable ha…
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psnet.ahrq.gov/node/49766/psn-pdf
August 21, 2016 - Getting the (Right) Doctor, Right Away
August 21, 2016
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
The Case
A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery.
Postop…
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psnet.ahrq.gov/node/73303/psn-pdf
May 26, 2021 - Safety Culture in EMS
May 26, 2021
Cebollero C, Fitall E, Hall KK, et al. Safety Culture in EMS. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/safety-culture-ems
Defining a Just Culture
A Just Culture is one that supports transparent and honest error reporting with the goal of fostering an
environmen…
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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…
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psnet.ahrq.gov/node/33790/psn-pdf
August 01, 2015 - New Insights on Safety and Health IT
August 1, 2015
Hettinger ZA, Ratwani RM, Fairbanks RJ. New Insights on Safety and Health IT. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
Perspective
Despite the widespread adoption of electronic health records (EHRs) over the las…
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psnet.ahrq.gov/node/49500/psn-pdf
January 01, 2006 - Confusion With Acetaminophen
January 1, 2006
Heubi JE. Confusion With Acetaminophen. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/confusion-acetaminophen
The Case
Parents brought their 5-year-old son to the emergency department (ED) with a 24-hour history of fever,
cough, and frontal headache. Physical e…
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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…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.356_slideshow.ppt
September 01, 2015 - PowerPoint Presentation
Spotlight
Abdominal Pain in Early Pregnancy
This presentation is based on the September 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Charlie C. Kilpatrick, MD, Associate Professor of Obstetrics and Gynecology, Baylor …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
September 01, 2003 - Spotlight Case September 2003
Spotlight Case September 2003
Infant Paralyzed for Intubation Before Airway Materials Ready
Source and Credits
This presentation is based on the Sept. 2003 AHRQ WebM&M Spotlight Case in Pediatrics
See the full article at http://webmm.ahrq.gov
CME credit is available through the …
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psnet.ahrq.gov/node/73905/psn-pdf
October 06, 2021 - Health Equity and Maternal Health
October 6, 2021
Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/health-equity-and-maternal-health
Redefining Maternal Safety
Maternal safety refers to the safety of a person during pregnancy, childb…
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - Hemolysis Holdup
May 1, 2017
Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic
kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
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psnet.ahrq.gov/node/49689/psn-pdf
August 21, 2013 - Anesthesia: A Weighty Issue
August 21, 2013
Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
The Case
A 77-year-old woman was evaluated preoperatively in anticipation of an elective left hip arthroplasty. She
reported having a history of hyperte…
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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/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
December 15, 2024 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events
Citation Text:
Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Cit…
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - Alert Fatigue
Citation Text:
Alert Fatigue. 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
Download Ci…
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psnet.ahrq.gov/node/60220/psn-pdf
April 29, 2020 - appropriate for the step-down unit and that the patient did not need ICU-level care, given ICU
RN staffing limitations
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - words and body language that implicitly or explicitly criticize the caller for admitting his or her limitations
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psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - delivering family-centered care include family and provider stress, competing demands, and
organizational limitations
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - Take-Home Points
Have a preoperative discussion about post-operative activity limitations and pain