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  1. psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
    February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room Citation Text: Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…
  2. psnet.ahrq.gov/web-mm/turn-other-cheek
    October 26, 2010 - Turn the Other Cheek Citation Text: Starling J. Turn the Other Cheek. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
  3. psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
    December 01, 2014 - African Partnerships for Patient Safety: Lessons Learned Shams B. Syed, MD, MPH | December 1, 2014  Also Read a Conversation View more articles from the same authors. Citation Text: Syed SS. African Partnerships for Patient Safety: Lessons Learned. PSNet [intern…
  4. psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx Spotlight A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion Source and Credits • This presentation is based on the July 2023 AHRQ WebM&M Spotlight Case o See the full article at ht…
  5. psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show
    March 01, 2013 - The Literature on Health Care Simulation Education: What Does It Show? David A. Cook, MD, MHPE | March 1, 2013  Also Read a Conversation View more articles from the same authors. Citation Text: Cook DA. The Literature on Health Care Simulation Education: What Do…
  6. psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
    August 04, 2021 - SPOTLIGHT CASE The NSTEMI Curbside Consultation Citation Text: Villablanca AC, Wong GX. The NSTEMI Curbside Consultation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scho…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867986/psn-pdf
    March 24, 2025 - In Conversation with Edwin Boudreaux about Suicide Prevention March 24, 2025 Boudreaux E, Gale B, Mossburg SE. In Conversation with Edwin Boudreaux about Suicide Prevention. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention Editor’s note: Edwin Boudre…
  8. psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
    March 01, 2019 - Building a Safety Program in a Vast Health Care Network Paul E. Phrampus, MD | March 1, 2019  Also Read a Conversation View more articles from the same authors. Citation Text: Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet].…
  9. psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
    February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common? Mark L. Graber, MD | February 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpi…
  10. psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
    February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness Suzanne Beyea, RN, PhD | February 1, 2014  Also Read the Conversations In Conversation With… Enrico Coiera, MB, BS, PhD In Conversation With… Richard Kronick, PhD View more …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861882/psn-pdf
    January 31, 2024 - Patient Safety in Office-Based Care Settings January 31, 2024 Ricciardi R, Lee M, Mossburg S. Patient Safety in Office-Based Care Settings. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings The Institute of Medicine’s 2000 publication To Err Is Human summarized res…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866848/psn-pdf
    September 25, 2024 - In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 25, 2024 Thomas E, Mossburg S, Lee M. In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement. …
  13. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
    August 01, 2014 - PowerPoint Presentation Spotlight Pitfalls in Diagnosing Necrotizing Fasciitis This presentation is based on the July/August 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hos…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49417/psn-pdf
    October 01, 2003 - Lost in the Black Hole October 1, 2003 Wachter R. Lost in the Black Hole. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/lost-black-hole The Case A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis. She had a remote history of gonorrhea, no environmental exposu…
  15. psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
    September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications Citation Text: Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33731/psn-pdf
    June 01, 2012 - An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up June 1, 2012 Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom Perspecti…
  17. psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
    November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012  View more articles from the same authors. Citation Text: Joseph A, Malone EB. The Physical Environment: An Often Unc…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49512/psn-pdf
    May 01, 2006 - Right? Left? Neither! May 1, 2006 Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/right-left-neither Case Objectives Appreciate the role of Reason's Swiss Cheese Model in medical errors Understand the process of analyzing a single error Provide suggestions for …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33618/psn-pdf
    September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety September 1, 2005 Wachter R. Playing Well with Others: "Translocational Research" in Patient Safety. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety Perspective Translation…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50612/psn-pdf
    October 30, 2019 - The Safety Challenges of Supervision and Night Coverage in Academic Residency October 30, 2019 Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency The Case…

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