-
psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - Linking Patient Safety Culture to Quality Ratings in the Nursing Home Setting.
-
psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - Linking Patient Safety Culture to Quality Ratings in the Nursing Home Setting.
-
psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
-
psnet.ahrq.gov/node/49575/psn-pdf
November 01, 2008 - Sick and Pregnant
November 1, 2008
El-Ibiary S. Sick and Pregnant. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/sick-and-pregnant
The Case
A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty
breathing. The patient informed the staff that she was 17 weeks pre…
-
psnet.ahrq.gov/node/49686/psn-pdf
May 01, 2013 - Don't Use That Port: Insert a PICC
May 1, 2013
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
The Case
A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with
fever and abdominal pain. A comp…
-
psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - One Dose, Fifty Pills
November 1, 2005
Smith L. One Dose, Fifty Pills . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/one-dose-fifty-pills
The Case
A middle-aged man was admitted to the medical service of a teaching hospital with suspected vasculitis.
When the initial diagnostic studies failed to provide …
-
psnet.ahrq.gov/web-mm/fumbled-handoff
September 01, 2006 - Fumbled Handoff
Citation Text:
Vidyarthi A. Fumbled Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
-
psnet.ahrq.gov/web-mm/peripheral-iv-too-long
September 15, 2011 - SPOTLIGHT CASE
Peripheral IV in Too Long
Citation Text:
Fang C-T. Peripheral IV in Too Long. 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 End…
-
psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Andrew P.J. …
-
psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
Citation Text:
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
Form…
-
psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - Project BOOST Increases Patient Understanding of
Treatment and Follow-up Care
May 26, 2021
https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
Summary
The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge
needs,…
-
psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - Supervision and Entrustment in Clinical Training:
Protecting Patients, Protecting Trainees
November 1, 2018
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees.
PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-pr…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
September 01, 2012 - Spotlight Case July 2008
Spotlight Case
Peripheral IV in Too Long
1
2
Source and Credits
This presentation is based on the September 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Chi-Tai Fang, MD, PhD; Associate Professor, National Taiwan Uni…
-
psnet.ahrq.gov/node/49453/psn-pdf
July 01, 2004 - Bowel Prep
July 1, 2004
Nelson D. Bowel Prep. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/bowel-prep
The Case
The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her
daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…
-
psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - Misconnection Leading to Arterial Thrombosis
Citation Text:
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
Google Scholar Bib…
-
psnet.ahrq.gov/web-mm/no-bp-during-nibp
March 01, 2011 - No BP During NIBP
Citation Text:
Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
-
psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - Diffusion of Responsibility Leads to Danger
Citation Text:
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar…
-
psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
September 27, 2023 - SPOTLIGHT CASE
Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation
Citation Text:
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. Rockville (MD): Agency for Health…
-
psnet.ahrq.gov/node/33752/psn-pdf
August 01, 2013 - In Conversation With… J. Bryan Sexton, PhD, MA
August 1, 2013
In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
Editor's note: J. Bryan Sexton, PhD, is associate professor and director of the Patient Safety Center for
the D…
-
psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
January 01, 2020 - Spotlight
The Lost Start Date, an Unknown
Risk of E-prescribing
Source and Credits
• This presentation is based on the October 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Adam Wright, PhD, and Gordon
Schiff, MD
○ Editor, AHRQ…