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psnet.ahrq.gov/primer/nursing-and-patient-safety
September 15, 2024 - Same Author(s)
WebM&M Cases
Multiple Levels Involved in Prescribing
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psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
January 13, 2021 - Decision support around penicillin allergies can be incorporated into antibiotic prescribing and sepsis
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - Challenges include but are not limited to 16
Decreased access to clinical decision support tools for prescribing
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - August 26, 2020
Prescribing patterns of heart failure-exacerbating medications following
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - November 16, 2022
Opioid prescribing for acute pain management in children and adolescents
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - We know that errors in prescribing, dispensing, and administering medications represent a substantial
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - The care these doctor/parents provided included otoscopy, chest auscultation, and antibiotic prescribing
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - October 31, 2011
Opioid prescribing for acute pain management in children and adolescents
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
September 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case September 2007
Medication Reconciliation: Whose Job Is It?
Source and Credits
This presentation is based on the September 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Eric G. Poon, MD, MPH, Ha…
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psnet.ahrq.gov/node/33813/psn-pdf
August 01, 2016 - Safety In Dentistry
August 1, 2016
Ramoni R, Walji MF, Kalenderian E. Safety In Dentistry. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/safety-dentistry
Perspective
In a famous scene from the 1976 film, Marathon Man, Laurence Olivier, playing dentist Dr. Christian Szell
tortures Babe Levy (played by…
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…
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psnet.ahrq.gov/node/49560/psn-pdf
April 01, 2008 - The Wrongful Resuscitation
April 1, 2008
Teno JM. The Wrongful Resuscitation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrongful-resuscitation
The Case
An 80-year-old man with diabetes, peripheral vascular disease, bilateral below-the-knee amputations, and
poor quality of life had previously been r…
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psnet.ahrq.gov/node/49479/psn-pdf
April 01, 2005 - The Forgotten Med
April 1, 2005
Cucina R. The Forgotten Med. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/forgotten-med
The Case
A 78-year-old woman with a history of chronic obstructive pulmonary disease (COPD) came to the hospital
with increasing shortness of breath and chest pain. Although she had no …
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
August 30, 2023 - Strategies to Improve Organizational Health Literacy.
Citation Text:
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:…
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - Wrong Route for Nutrients
Citation Text:
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/web-mm/missed-tb
March 03, 2010 - Missed TB
Citation Text:
FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/33701/psn-pdf
October 01, 2010 - What Makes a Good Checklist
October 1, 2010
McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/what-makes-good-checklist
Perspective
The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex
tasks. Checklists have lo…
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psnet.ahrq.gov/node/853981/psn-pdf
September 27, 2023 - Walking Out of a Hospital After Attempted Suicide
September 27, 2023
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
The Case
A 42-year-old man with history of posttraumatic stress disorder …
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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…