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psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - Patient and Family Roles in Safety
June 14, 2023
Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety
Moving From Engagement to Partnership
Involving patients and families in healthcare decisions about patient c…
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - Who Nose Where the Airway Is?
Citation Text:
Lee CR. Who Nose Where the Airway Is?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - July Syndrome
Citation Text:
Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
D…
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017037-ornstein-final-report-2010.pdf
January 01, 2010 - Medication Safety in Primary Care Practice Translating Research into Practice (MS-TRIP)
Grant Final Report
Grant ID: 5R18HS017037
Medication Safety in Primary Care Practice
Translating Research into Practice (MS-TRIP)
Inclusive Dates: 09/30/07 – 09/29/10
Principal Investigator:
Ste…
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psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue
Citation Text:
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Cit…
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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical
Record Causing an Accidental Medication Overdose
October 31, 2023
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an
Accidental Medication Overdose. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/weight-and-…
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psnet.ahrq.gov/sites/default/files/2021-04/final_psnet_spotlight_retained_vaginal_packing_04.08.2021.pdf
January 01, 2021 - Spotlight
Spotlight
Two Cases of Retained Vaginal Packing:
When Writing an Order is Not Enough
Source and Credits
• This presentation is based on the April 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Verna Gibbs, MD
o AHRQ W…
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psnet.ahrq.gov/node/33714/psn-pdf
July 01, 2011 - In Conversation with…William B. Munier, MD, MBA
July 1, 2011
In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
Editor's note: William B. Munier, MD, MBA, is the Director of the Center for Quality Improvement and
Pati…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Miller_93.pdf
March 12, 2008 - Evaluation of Medications Removed from Automated Dispensing Machines Using the Override Function Leading to Multiple System Changes
Evaluation of Medications Removed from Automated
Dispensing Machines Using the Override Function
Leading to Multiple System Changes
Karla Miller, PharmD; Manisha Shah, MBA, RT; Lau…
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psnet.ahrq.gov/node/73456/psn-pdf
June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult
Intubation and Severe Hypoxemia
June 30, 2021
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - Near Miss with Bedside Medications
November 1, 2011
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications
Case Objectives
Understanding the definition of near miss—also known as close call.
Appreciate the importance of close calls in reducin…
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psnet.ahrq.gov/node/49865/psn-pdf
June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy
June 1, 2019
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
The Case
A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
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psnet.ahrq.gov/node/49816/psn-pdf
January 01, 2018 - A Painful Medication Reconciliation Mishap
January 1, 2018
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
Case Objectives
Recognize that substance use disorders are common in patients with acute pain.
Understand th…
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www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/webinars/perinatal-care-experience-slides.pdf
March 06, 2025 - Factors that Impact Perinatal Care Experience and Outcomes: Slide Presentation
National Center for Excellence in Primary Care Research
Presents
Factors that Impact Perinatal Care Experience and Outcomes
March 6, 2025
Presented by:
Amy G. Cantor MD, MPH, FAAFP
Lindsay Kennedy Admon, MD, MSc
Mark Allen Clapp, …
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
https…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/035-importance-mrsa-prevention-notes.docx
October 01, 2024 - AHRQ Safety Program for MRSA Prevention
The Importance of MRSA Prevention
ICU & Non-ICU
Slide Title and Commentary
Slide Number and Slide
The Importance of MRSA Prevention
SAY:
Welcome to this presentation on the Importance of Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention. This presentation will ou…
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psnet.ahrq.gov/node/49663/psn-pdf
September 01, 2012 - Peripheral IV in Too Long
September 1, 2012
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/peripheral-iv-too-long
Case Objectives
Appreciate the complications associated with peripheral intravenous (IV) catheters.
Describe the optimal sterile technique that should be us…
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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - Errors in Sepsis Management
May 1, 2015
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/errors-sepsis-management
Case Objectives
Define sepsis, severe sepsis, and septic shock.
Describe the severe sepsis/septic shock resuscitation bundle.
Recognize commonly encou…
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psnet.ahrq.gov/node/60857/psn-pdf
August 26, 2020 - Nothing Called Small Surgery
August 26, 2020
Manske C. Nothing Called Small Surgery. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/nothing-called-small-surgery
The Case
A 56-year-old female presented to surgical clinic with pain and swelling in left great toe associated with
progressive deformity of the …
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www.ahrq.gov/sites/default/files/2024-02/ornstein-report.pdf
January 01, 2024 - Final Progress Report: Medication Safety in Primary Care Practice Translating Research Into Practice (MS-TRIP)
Grant Final Report
Grant ID: 5R18HS017037
Medication Safety in Primary Care Practice
Translating Research into Practice (MS-TRIP)
Inclusive Dates: 09/30/07 – 09/29/10
Principal Investigator:
Steven Ornst…