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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…
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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 …
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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.
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Format:
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…
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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…
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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.
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Format:
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Downloa…
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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…
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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.
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…
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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, …
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psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Lethal Cap
Citation Text:
Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Do…
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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
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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
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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…
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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
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - , 2022
Incidence and characteristics of errors detected by a short team briefing in pediatric
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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - In 2013, the Society of Hospital Medicine released Pedi-BOOST, which incorporated unique pediatric-
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - October 15, 2014
Medical diagnoses commonly associated with pediatric malpractice lawsuits
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - The Case
A 3-month-old infant was admitted with a respiratory syncytial virus (RSV) infection to a pediatric
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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - Dellinger RP, Levy MM, Rhodes A, et al; Surviving Sepsis Campaign Guidelines Committee including
the Pediatric
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psnet.ahrq.gov/node/49540/psn-pdf
August 21, 2007 - External paddles (including pediatric adapters)* a. Clean, not
pitted b.