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  1. psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
    April 26, 2023 - Annual Perspective Technology as a Tool for Improving Patient Safety A Jay Holmgren, Susan McBride,Bryan Gale, Sarah Mossburg | March 29, 2023  View more articles from the same authors. Citation Text: Holmgren AJ, McBride S, Gale B, et al. Technology as a …
  2. psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
    October 02, 2019 - SPOTLIGHT CASE One Toxic Drug Is Not Like Another Citation Text: Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTe…
  3. psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
    May 01, 2018 - SPOTLIGHT CASE Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency Citation Text: Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  4. psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
    April 04, 2018 - SPOTLIGHT CASE The Pains of Chronic Opioid Usage Citation Text: Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google S…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867357/psn-pdf
    December 18, 2024 - Hypoxemia after Emergency Intubation December 18, 2024 Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation The Case A 19-month-old child was brought to the emergency department (ED) via ambulance after drowning in a p…
  6. psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
    June 30, 2021 - In Conversation With... Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA June 30, 2021  Also Read the Essay Citation Text: In Conversation With.. Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA. PSNet [internet]. 2021.In Conversation…
  7. psnet.ahrq.gov/perspective/covid-19-and-built-environment
    June 30, 2021 - COVID-19 and the Built Environment June 30, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Joseph A, Scanlon MM, Fitall E, et al. COVID-19 and the Built Environment. PSNet [internet]. Rockville (MD): Agency for Healthca…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50844/psn-pdf
    January 29, 2020 - Improving Patient Safety and Team Communication through Daily Huddles January 29, 2020 Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles Background Communicat…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49416/psn-pdf
    September 01, 2003 - Check the Bags September 1, 2003 Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/check-bags The Case A 50-year-old man with new atrial fibrillation was placed on a diltiazem drip in the emergency department for rate control. After arriving at the cardiac care unit (CCU…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49410/psn-pdf
    July 01, 2003 - A Little Shuteye July 1, 2003 Farion KJ. A Little Shuteye. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/little-shuteye The Case A 3-year-old boy was seen in urgent care for a superficial laceration above the left eyebrow. The pediatrician had heard of the availability of topical skin adhesive that can be…
  11. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
    January 01, 2015 - Spotlight Case [MONTH] 2003 Spotlight Case February 2007 The ‘Customer’ Is Always Right Source and Credits This presentation is based on the February 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: Niraj L. Sehgal,…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33617/psn-pdf
    August 01, 2005 - In Conversation with…Barbara A. Blakeney, MS, RN August 1, 2005 In Conversation with…Barbara A. Blakeney, MS, RN. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn Editor's Note: Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses Associa…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33794/psn-pdf
    November 01, 2015 - In Conversation With… Lorri Zipperer, MA November 1, 2015 In Conversation With… Lorri Zipperer, MA. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma Editor's note: Lorri Zipperer, principal at Zipperer Project Management, was a founding staff member of the National Patient…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33627/psn-pdf
    February 01, 2006 - Removing Insult from Injury—Disclosing Adverse Events February 1, 2006 Wu AW. Removing Insult from Injury—Disclosing Adverse Events. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events Perspective You pull into a parking space, swing open the car door, and ar…
  15. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
    June 01, 2004 - Spotlight Case [MONTH] 2003 Spotlight Case June 2004 The Wrong Shot: Error Disclosure Source and Credits This presentation is based on the June 2004 AHRQ WebM&M Spotlight Case in Pediatrics CME credit is available through the Web site See the full article at http://webmm.ahrq.gov Commentary by: Thomas H. …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867004/psn-pdf
    October 30, 2024 - Critical Radiology Alert Process October 30, 2024 https://psnet.ahrq.gov/innovation/critical-radiology-alert-process Summary Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of unrelated abnormal findings and provides a companion follow-up process, with the goal o…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49511/psn-pdf
    May 01, 2006 - Citrate Mix-Up May 1, 2006 Weber RJ. Citrate Mix-Up. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/citrate-mix The Case A 36-year-old woman with multiple sclerosis, diabetes, and chronic renal failure was transferred from a skilled nursing facility (SNF) to the hospital for treatment of an infection. On a…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33753/psn-pdf
    August 22, 2013 - Update on Safety Culture August 22, 2013 Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/update-safety-culture Perspective Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians treat each other with r…
  19. psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
    March 07, 2018 - SPOTLIGHT CASE Too Many Cooks in the Kitchen Citation Text: Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X…
  20. psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
    January 29, 2021 - Misconnection Leading to Arterial Thrombosis Citation Text: Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bib…

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