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psnet.ahrq.gov/web-mm/preventable-rash
October 01, 2012 - Preventable Rash
Citation Text:
McLean C. Preventable Rash. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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…
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psnet.ahrq.gov/web-mm/ventricular-wall-injury-during-diagnostic-cardiac-catheterization
September 01, 2012 - Ventricular Wall Injury during a Diagnostic Cardiac Catheterization
Citation Text:
Pham TH, Atreja S. Ventricular Wall Injury during a Diagnostic Cardiac Catheterization. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - Pathologic Mistake
Citation Text:
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - CVC Removal: A Procedure Like Any Other
Citation Text:
Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
June 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case June 2007
Beeline to Spine
Source and Credits
This presentation is based on June 2007
AHRQ WebM&M Spotlight Case
See full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Gerald W. Smetana, MD, Harvard Medical School, Beth Israel D…
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psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
July 01, 2017 - Shortcuts to Acetaminophen-induced Liver Failure
Citation Text:
Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfer Troubles
1
2
Source and Credits
This presentation is based on the June 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…
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psnet.ahrq.gov/node/49544/psn-pdf
September 01, 2007 - Discharging Our Responsibility
September 1, 2007
Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/discharging-our-responsibility
The Case
A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure
(CHF) presented to the …
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psnet.ahrq.gov/print/pdf/node/865864
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Error
Curated Library
Incidence of Diagnostic Errors
25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the
National Practitioner Data Bank.
Tehrani ASS, Lee HW, Mathews SC, et al. BMJ Qua…
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - January 22, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/node/47282/psn-pdf
August 08, 2018 - Making surgical wards safer for patients with diabetes:
reducing hypoglycaemia and insulin errors.
August 8, 2018
Singh A, Adams A, Dudley B, et al. Making surgical wards safer for patients with diabetes: reducing
hypoglycaemia and insulin errors. BMJ Open Qual. 2018;7(3):e000312. doi:10.1136/bmjoq-2017-000312.
ht…
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psnet.ahrq.gov/node/837424/psn-pdf
June 15, 2022 - Allergy safety events in healthcare: development and
application of a classification schema based on
retrospective review.
June 15, 2022
Phadke NA, Wickner PG, Wang L, et al. Allergy safety events in healthcare: development and application
of a classification schema based on retrospective review. J Allergy Clin Im…
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psnet.ahrq.gov/node/45117/psn-pdf
August 03, 2016 - Using computerized prescriber order entry to limit
overrides from automated dispensing cabinets.
August 3, 2016
Drake E, Srinivas P, Trujillo T. Using computerized prescriber order entry to limit overrides from automated
dispensing cabinets. Am J Health-Syst Pharm. 2016;73(14):1033-1035. doi:10.2146/ajhp150564.
ht…
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psnet.ahrq.gov/node/60057/psn-pdf
March 18, 2020 - How does the WHO Surgical Safety Checklist fit with
existing perioperative risk management strategies? An
ethnographic study across surgical specialties.
March 18, 2020
Wæhle HV, Haugen AS, Wiig S, et al. How does the WHO Surgical Safety Checklist fit with existing
perioperative risk management strategies? An ethn…
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psnet.ahrq.gov/node/40448/psn-pdf
September 19, 2016 - Health care workers as second victims of medical errors.
September 19, 2016
Edrees HH, Paine LA, Feroli R, et al. Health care workers as second victims of medical errors. Pol Arch
Med Wewn. 2011;121(4):101-108.
https://psnet.ahrq.gov/issue/health-care-workers-second-victims-medical-errors
Medical errors can have a…
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psnet.ahrq.gov/node/40037/psn-pdf
September 20, 2011 - Adverse Events in Hospitals: National Incidence Among
Medicare Beneficiaries.
September 20, 2011
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector
General; November 2010. Report No. OEI-06-09-00090.
https://psnet.ahrq.gov/issue/adverse-events-hospitals-national-incide…
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psnet.ahrq.gov/node/44247/psn-pdf
November 03, 2015 - Effects of interdisciplinary team care interventions on
general medical wards: a systematic review.
November 3, 2015
Pannick S, Davis R, Ashrafian H, et al. Effects of Interdisciplinary Team Care Interventions on General
Medical Wards: A Systematic Review. JAMA Intern Med. 2015;175(8):1288-98.
doi:10.1001/jamainte…
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psnet.ahrq.gov/node/42692/psn-pdf
April 21, 2015 - Surgical skill and complication rates after bariatric
surgery.
April 21, 2015
Birkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl
J Med. 2013;369(15):1434-1442. doi:10.1056/NEJMsa1300625.
https://psnet.ahrq.gov/issue/surgical-skill-and-complication-rates…
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psnet.ahrq.gov/node/867606/psn-pdf
February 10, 2025 - AHRQ PSNet Annual Webinar: Evidence on Advancing
Rapid Response Systems and Opioid Stewardship.
January 22, 2025
Agency for Healthcare Quality and Research. AHRQ PSNet Annual Webinar: Evidence on Advancing
Rapid Response Systems and Opioid Stewardship. February 10, 2025, 1:00pm-2:00pm (eastern).
https://psnet.ahrq…
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psnet.ahrq.gov/issue/when-doctor-too-old-job
March 04, 2020 - Newspaper/Magazine Article
When is a doctor too old for the job?
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September 18, 2019
Potential deterioration of an aging surgeon's…