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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - Spotlight Case July 2008
Spotlight Case
Right Regimen, Wrong Cancer: Patient Catches Medical Error
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Source and Credits
This presentation is based on the May 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph O. Jacobson, MD, MSc…
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psnet.ahrq.gov/node/33854/psn-pdf
March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety
March 1, 2018
Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
Perspective
Errors in hospitals remain a major cause of death.(1…
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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
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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/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/node/33725/psn-pdf
February 01, 2012 - Balancing Supervision and Autonomy: An Ongoing
Tension
February 1, 2012
Dine JC, Myers JS. Balancing Supervision and Autonomy: An Ongoing Tension. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
Perspective
Graduate Medical Education (GME) has changed …
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psnet.ahrq.gov/node/33755/psn-pdf
September 01, 2013 - What We've Learned About Leveraging Leadership and
Culture to Affect Change and Improve Patient Safety
September 1, 2013
Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve
Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - Triggers and Trigger Tools
Citation Text:
Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - attributed to either medication errors involving wrong dose or improper monitoring. 14
The overwhelming majority
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - approximately 15% of patients with previous abdominal surgery. 10 Adhesion disease is the cause in the majority
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psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
September 01, 2014 - Although most patients with serious illness say that they would prefer to die at home, the majority of
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psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
March 30, 2020 - We are expanding outside of the hospital space, but that’s where the vast majority of our experience
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - Two patient safety practices:
► Rapid Response Systems
► Opioid Stewardship
• Encouraged by the majority
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psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
March 30, 2020 - We are expanding outside of the hospital space, but that’s where the vast majority of our experience
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psnet.ahrq.gov/node/33750/psn-pdf
May 01, 2013 - The majority of hospitals now are reporting those to
the CDC.
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - have been consistently summarized in the family medicine and internal medicine literature. 2-5 The majority
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psnet.ahrq.gov/perspective/overuse-patient-safety-problem
September 01, 2014 - Although most patients with serious illness say that they would prefer to die at home, the majority of
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - many family caregivers to feel overwhelmed and inadequately prepared.25 Adding to the complexity, the
majority
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - Despite persistent fears regarding the potential hemorrhagic complications associated with rtPA use, the majority
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psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
November 02, 2016 - Promising Areas for Patient Safety Research
P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH | December 1, 2003
View more articles from the same authors.
Citation Text:
Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. …
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psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
May 31, 2023 - In Conversation With… Vineet Arora, MD, MAPP
September 1, 2015
Citation Text:
In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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