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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error
Citation Text:
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - Chemotherapy Administration Safety Standards
September 1, 2018
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
The Case
A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…
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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Central, not Epidural
September 1, 2011
Simmons D. Central, not Epidural. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/central-not-epidural
The Case
A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively,
he was awake, alert, and oriented to time, place,…
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the
Senior Clinical Data Analyst at Atrium Health, and Rhonda
Dickman, MSN, RN, CPHQ, the Director of the Tennessee
Hospital Association PSO
January 12, 2022
In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and
Rhonda…
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Mother's Milk, but Whose Mother?
Citation Text:
Dougherty D. Mother's Milk, but Whose Mother?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - In Conversation with...Sorrel King
March 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Sorrel King. PSNet [internet]. 2007.In Conversation with...Sorrel King. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/node/857061/psn-pdf
November 27, 2023 - In Conversation with... Joan Stanley about The Role of
Undergraduate Nursing Education in Patient Safety
November 27, 2023
Stanley J. In Conversation with.. Joan Stanley about The Role of Undergraduate Nursing Education in
Patient Safety . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-joa…
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psnet.ahrq.gov/node/49414/psn-pdf
September 01, 2003 - Making Do
September 1, 2003
Bradley LD. Making Do. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/making-do
The Case
A 56-year-old female with dysfunctional uterine bleeding and possible retained intrauterine device (IUD)
was scheduled for elective hysteroscopy and dilation and curettage (D&C). Of note, sh…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.ppt
November 01, 2018 - Spotlight
Spotlight
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
*
Source and Credits
This presentation is based on the November 2018 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Olle ten C…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
March 01, 2011 - Spotlight Case July 2008
Spotlight Case March 2011
Volume Too Low: In and Out
Pediatric Patient Safety
*
*
Source and Credits
This presentation is based on the March 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Marlene Miller, MD, MSc…
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psnet.ahrq.gov/node/46183/psn-pdf
July 12, 2017 - Medication-related Malpractice Risks. 2016 CRICO
Strategies National CBS Report.
July 12, 2017
Boston, MA: CRICO Strategies; 2017.
https://psnet.ahrq.gov/issue/medication-related-malpractice-risks-2016-crico-strategies-national-cbs-report
Medication errors are a persistent challenge in health care that can occur a…
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psnet.ahrq.gov/node/40657/psn-pdf
August 03, 2011 - Effectiveness and cost of a transitional care program for
heart failure: a prospective study with concurrent
controls.
August 3, 2011
Stauffer BD, Fullerton C, Fleming N, et al. Effectiveness and cost of a transitional care program for heart
failure: a prospective study with concurrent controls. Arch Intern Med. 2…
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - Syringe Swap During Regional Block: A Case of
Medication Error and Recovery
January 31, 2024
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
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psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx
Spotlight
Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
Source and Credits
• This presentation is based on the March 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/…
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psnet.ahrq.gov/issue/patient-safety-essentials-toolkit
January 08, 2020 - Toolkit
Patient Safety Essentials Toolkit.
Citation Text:
Patient Safety Essentials Toolkit. Boston, MA: Institute for Healthcare Improvement; 2019.
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psnet.ahrq.gov/issue/what-happened-patient-safety
August 23, 2007 - Audiovisual
What Happened to Patient Safety.
Citation Text:
What Happened to Patient Safety. Sheridan S. Turn on the Lights. Institute for Healthcare Improvement. May 2023
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psnet.ahrq.gov/issue/hospitals-two-states-denied-abortion-miscarrying-patient-investigators-say-they-broke-federal
September 20, 2023 - Newspaper/Magazine Article
Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law.
Citation Text:
Hospitals in two states denied an abortion to a miscarrying patient. Investigators say they broke federal law. Surana K. Pro Publica. M…
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psnet.ahrq.gov/issue/focus-computerized-provider-order-entry
March 11, 2020 - Special or Theme Issue
Focus on Computerized Provider Order Entry.
Citation Text:
Focus on Computerized Provider Order Entry. J Am Med Inform Assoc. 2007 Jan-Feb;14(1):25-75
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psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center
May 02, 2018 - Newspaper/Magazine Article
Inside the preventable deaths that happened within a prominent transplant center.
Citation Text:
Inside the preventable deaths that happened within a prominent transplant center. Blau M. ProPublica. June 14, 2023.
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psnet.ahrq.gov/issue/medication-therapy-management-programs-forming-new-cornerstone-quality-and-safety-medicare
January 06, 2017 - Commentary
Medication therapy management programs: forming a new cornerstone for quality and safety in Medicare.
Citation Text:
Smith SR, Clancy CM. Medication therapy management programs: forming a new cornerstone for quality and safety in medicare. Am J Med Qual. 2006;21(4):276-9.
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