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  1. 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.
  2. psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
    July 10, 2024 - Linking Patient Safety Culture to Quality Ratings in the Nursing Home Setting.
  3. 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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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 …
  7. 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 …
  8. 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…
  9. 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. …
  10. 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…
  11. Psn-Pdf (pdf file)

    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,…
  12. Psn-Pdf (pdf file)

    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…
  13. 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…
  14. Psn-Pdf (pdf file)

    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…
  15. 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…
  16. 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…
  17. 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…
  18. 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…
  19. Psn-Pdf (pdf file)

    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…
  20. 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…

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