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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
    April 01, 2015 - PowerPoint Presentation Spotlight Dissecting the Presentation * This presentation is based on the April 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Shirley Beng Suat Ooi, MBBS (S'pore), Emergency Medicine Department, National Univers…
  2. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
    June 01, 2013 - Spotlight Case July 2008 Spotlight Case Emergency Error 1 2 Source and Credits This presentation is based on the June 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London Editor, AHRQ WebM&M: Robe…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33856/psn-pdf
    April 01, 2018 - Patient Safety During Hospital Discharge April 1, 2018 Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge Perspective Patients are admitted to the hospital in the United States 35 million times per year.(1)…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867652/psn-pdf
    February 26, 2025 - The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis Introduction Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
    January 01, 2021 - Spotlight Spotlight The Consequences of Miscommunication Regarding a Possible Artifact Source and Credits • This presentation is based on the June 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Kriti Gwal, MD o AHRQ WebM&M Edit…
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
    October 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case October 2007 Do Not Disturb! Source and Credits This presentation is based on the October 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available online Commentary by: F. Daniel Duffy, MD, University of Oklahoma, and…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865697/psn-pdf
    April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges April 24, 2024 Leary KB. In Conversation with..Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-a…
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
    September 01, 2006 - Spotlight Case September 2006 Spotlight Case September 2006 Triple Handoff Source and Credits This presentation is based on the September 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Arpana Vidyarthi, MD, UCSF Sc…
  9. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
    March 01, 2012 - Spotlight Case July 2008 Spotlight Case Postdischarge Follow-Up Phone Call * * Source and Credits This presentation is based on the March 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Michelle Mourad, MD, and Stephanie Rennke, MD; Divi…
  10. psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx Spotlight When the Indications for Drug Administration Blur Source and Credits • This presentation is based on the June 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Julia Munsch,…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33694/psn-pdf
    April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010 In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a priva…
  12. 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…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49756/psn-pdf
    April 01, 2016 - Lost in Sign Out and Documentation April 1, 2016 Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation The Case A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the emergency physician, …
  14. 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…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49424/psn-pdf
    November 01, 2003 - Waiting Too Long November 1, 2003 Rosen MA. Waiting Too Long. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/waiting-too-long The Case A 31-year-old gravida 1, para 1 woman presented at 40 weeks in the early stages of labor having received limited prenatal care at an outside clinic. Physical exam performed…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33628/psn-pdf
    February 01, 2006 - In Conversation with…John Banja, PhD February 1, 2006 In Conversation with…John Banja, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd Editor's Note: John Banja, PhD, is Assistant Director for Health Sciences and Clinical Ethics and Associate Professor of Clinical Et…
  17. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
    January 01, 2020 - Spotlight Spotlight Discharged with IV antibiotics: When issues arise, who manages the complications? Source and Credits • This presentation is based on the February 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Monica Donnel…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49683/psn-pdf
    April 01, 2013 - Acute Care Admission of the Behavioral Health Patient April 1, 2013 Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient The Case A 25-year-old man presented to the emergency department (E…
  19. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
    December 01, 2013 - PowerPoint Presentation Spotlight Case New Oral Anticoagulants 1 This presentation is based on the December 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Margaret C. Fang, MD, MPH, University of California, San Francisco Editor, AHRQ WebM&M…
  20. psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
    December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles Citation Text: Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citatio…

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