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psnet.ahrq.gov/web-mm/dropping-new-lows
December 18, 2024 - SPOTLIGHT CASE
Dropping to New Lows
Citation Text:
Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - She may have been admitted to the antepartum service or perhaps prescribed the medication based on her
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psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
September 01, 2017 - In Conversation With… Andrew Gettinger, MD
September 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Andrew Gettinger, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes
Ross Koppel, PhD | July 1, 2012
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Koppel R. Patient Safety and Health Information Technology: Learning f…
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psnet.ahrq.gov/glossary
January 01, 2003 - Unfortunately, harm does not only occur from receipt of these inappropriately prescribed medications.
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psnet.ahrq.gov/glossary-0
January 01, 2003 - Unfortunately, harm does not only occur from receipt of these inappropriately prescribed medications.
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psnet.ahrq.gov/primer/health-literacy
September 07, 2019 - Health Literacy
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September 7, 2019
Background
Health literacy is defined as an individual's ability to find, process, and comprehend the basic health information necessary…
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psnet.ahrq.gov/primer/duty-hours-and-patient-safety
June 15, 2024 - Duty Hours and Patient Safety
Citation Text:
Duty Hours and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49743/psn-pdf
September 01, 2015 - Dual Therapy Debacle
September 1, 2015
Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/dual-therapy-debacle
The Case
An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction,
hyperlipidemia, obesity, and a long history of tobacco use …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - Spotlight Case July 2008
Spotlight Case
Right Regimen, Wrong Cancer: Patient Catches Medical Error
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Source and Credits
This presentation is based on the May 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph O. Jacobson, MD, MSc…
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - ED physicians diagnosed an infection, prescribed antibiotics, and told the patient to schedule an appointment
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - Albuterol was administered via mask, and a nasal cannula was prescribed with high-flow oxygen.
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - ED physicians diagnosed an infection, prescribed antibiotics, and told the patient to
schedule an appointment
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psnet.ahrq.gov/issue/producing-effective-treatment-enhancing-safety-medical-physicists-strategies-ensure-quality
July 12, 2023 - Study
Producing effective treatment, enhancing safety: medical physicists' strategies to ensure quality in radiotherapy.
Citation Text:
Nascimento A, Falzon P. Producing effective treatment, enhancing safety: medical physicists' strategies to ensure quality in radiotherapy. Appl Ergon.…
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
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psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
…
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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - Chemotherapy Administration Safety Standards
September 1, 2018
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
The Case
A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…
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psnet.ahrq.gov/node/50393/psn-pdf
September 01, 2019 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
Perspective
Progress in any field requires scholarship and dissem…
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psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
January 01, 2020 - Spotlight
Spotlight
Suicidal Ideation in the Family Medicine Clinic
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Source and Credits
This presentation is based on the December 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Christine Moutier, MD, Chief Medical Officer, American …
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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Patient Mix-Up
February 1, 2003
Shojania KG. Patient Mix-Up. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/patient-mix
The Case
Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general
medical service at an academic medical center. Overnight, another man wit…