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  1. A Little Shuteye | PSNet

    psnet.ahrq.gov/web-mm/little-shuteye
    December 22, 2018 - A Little Shuteye Citation Text: Farion KJ. A Little Shuteye. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867655/psn-pdf
    February 26, 2025 - Learning Health Systems for Patient Safety February 26, 2025 Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety Despite an observable decrease in adverse events in health care over time, rat…

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

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
    March 01, 2007 - Spotlight Case [MONTH] 2003 Spotlight Case March 2007 Failure to Report Source and Credits This presentation is based on the March 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…

  4. Shake Well | PSNet

    psnet.ahrq.gov/web-mm/shake-well
    September 01, 2006 - Shake Well Citation Text: Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downloa…

  5. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
    May 01, 2012 - Spotlight Case July 2008 Spotlight Case The Perils of Cross Coverage * * Source and Credits This presentation is based on the May 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …

  6. Misread Label | PSNet

    psnet.ahrq.gov/web-mm/misread-label
    August 28, 2024 - Misread Label Citation Text: Franklin BD. Misread Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49463/psn-pdf
    October 14, 2004 - Moved Too Soon October 1, 2004 Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/moved-too-soon The Case A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours after arriving, while the patient was still groggy from anesthesia, a nurs…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60653/psn-pdf
    April 25, 2020 - Health Care Delivery and Pharmacists During the COVID- 19 Pandemic June 29, 2020 Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic Medication…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49443/psn-pdf
    May 01, 2004 - Privacy Gone Awry May 1, 2004 Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/privacy-gone-awry The Case A 3-year-old child underwent bilateral myringotomies and tube insertion with adenoidectomy. Preoperatively, she had an upper respiratory infection, but was eating…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49515/psn-pdf
    July 01, 2006 - Over Not So Easy July 1, 2006 Cucina R. Over Not So Easy. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/over-not-so-easy The Case A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On admission, she reported allergies to a number of medications as well as a …

  11. Spotlight (ppt file)

    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…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850673/psn-pdf
    June 14, 2023 - In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm June 14, 2023 Johnson B. In Conversation with.. Beverley H. Johnson about The Role of Patient's Family In Reducing Harm. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-r…

  13. In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm | PSNet

    psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
    June 14, 2023 - emotional toll of the loss of family presence was rapidly apparent. 5 Given the unique role of families in pediatric

  14. Patient and Family Roles in Safety | PSNet

    psnet.ahrq.gov/perspective/patient-and-family-roles-safety
    June 14, 2023 - emotional toll of the loss of family presence was rapidly apparent. 5 Given the unique role of families in pediatric

  15. In Conversation with...Patrick S. Romano, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
    July 10, 2024 - In Conversation with...Patrick S. Romano, MD, MPH November 1, 2010  Citation Text: In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.In Conversation with...Patrick S. Romano, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

  16. Cultural Competence and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
    December 27, 2019 - experienced adverse events, and that harm was more likely to be severe. [11] These findings extend to pediatric

  17. Code Blue—Where To? | PSNet

    psnet.ahrq.gov/web-mm/code-blue-where
    March 30, 2020 - May 18, 2022 Misuse of pediatric medications and parent–physician communication: an interactive

  18. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions | PSNet

    psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
    November 13, 2024 - relationship between the patient and caregiver, length of professional relationships, cases that involved pediatric

  19. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
    January 01, 2024 - Impact of Simulation-Based Closed-Loop Communication Training on Medical Errors in a Pediatric Emergency

  20. How Do Providers Recover From Errors? | PSNet

    psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
    May 22, 2024 - Cases The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric
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