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  1. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

  2. The Need to Eat | PSNet

    psnet.ahrq.gov/web-mm/need-eat
    February 10, 2021 - The Need to Eat Citation Text: Widaman AM. The Need to Eat. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848108/psn-pdf
    April 26, 2023 - The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. April 26, 2023 Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/do…

  4. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.227_slideshow.ppt
    November 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Treatment Challenges After Discharge * * Source and Credits This presentation is based on the November 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Chase Coffey, MD, Henry Ford Health System,…

  5. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
    October 01, 2003 - Spotlight Case [MONTH] 2003 Spotlight Case October 2003 Hemivulvectomy: Wrong Side Removed Source and Credits This presentation is based on the Oct. 2003 AHRQ WebM&M Spotlight Case in OB/GYN See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Charles Vin…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49474/psn-pdf
    March 01, 2005 - Hidden Mystery March 1, 2005 Brunette DD. Hidden Mystery. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hidden-mystery Case Objectives Appreciate the challenges of caring for morbidly obese patients. List specific interventions that can be implemented when caring for obese patients. Develop a rational ap…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49744/psn-pdf
    October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy October 1, 2015 Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49614/psn-pdf
    November 01, 2010 - Reconciling Records November 1, 2010 Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/reconciling-records The Cases   Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local teaching hospital. When discharged, h…

  9. A "Weak" Response | PSNet

    psnet.ahrq.gov/web-mm/weak-response
    February 24, 2011 - A "Weak" Response Citation Text: Reisman AB. A "Weak" Response. 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 …

  10. Medication Reconciliation With a Twist (or Dare We Say, a Patch?) | PSNet

    psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
    April 03, 2024 - SPOTLIGHT CASE Medication Reconciliation With a Twist (or Dare We Say, a Patch?) Citation Text: Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…

  11. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications | PSNet

    psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
    February 01, 2004 - SPOTLIGHT CASE Delay in Treatment: Failure to Contact Patient Leads to Significant Complications Citation Text: Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49717/psn-pdf
    September 01, 2014 - A Lot of Pain (Medications) September 1, 2014 Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/lot-pain-medications Case Objectives Appreciate the challenges of managing acute pain in hospitalized patients on chronic opioids. Describe the importance of understanding th…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33867/psn-pdf
    October 01, 2018 - In Conversation With… Michael Cohen, RPh, MS, ScD (hon) October 1, 2018 In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0 Editor's note: Dr. Cohen is President of the Institute for Safe Medication Practice…

  14. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet

    psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
    January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery Citation Text: Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …

  15. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet

    psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
    September 30, 2020 - SPOTLIGHT CASE Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Citation Text: Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…

  16. Primary Care and Patient Safety: Opportunities at the Interface | PSNet

    psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
    September 28, 2022 - Primary Care and Patient Safety: Opportunities at the Interface September 28, 2022  Also Read the Conversations In Conversation With... Freya Spielberg, MD, MPH In Conversation With... Jack Westfall, MD, MPH View more articles from the same authors. …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866216/psn-pdf
    July 10, 2024 - Linking Patient Safety Culture to Quality Ratings in the Nursing Home Setting.

  18. Implementation of Patient Safety Projects | PSNet

    psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
    September 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Implementation of Patient Safety Projects  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybraria…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850361/psn-pdf
    June 14, 2023 - Critical Echocardiogram Result Lost to Follow-up June 14, 2023 Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow The Case A 63-year-old man with history of stroke, systolic heart failure, and ventric…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867850/psn-pdf
    February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/persp…
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