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psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
September 01, 2016 - necessary to effectively engage patients across the continuum of care that includes protecting and promoting
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced
Respiratory Depression
May 27, 2020
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-
…
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - When the Meds Don’t Reach the Bed
August 26, 2020
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
The Case
A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of
chronic obs…
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
March 27, 2024 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
Citation Text:
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citati…
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - A Tale of Two Falls
Citation Text:
Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - SPOTLIGHT CASE
Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery
Citation Text:
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.. PSNet [internet]…
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - A Tale of Two Falls
October 30, 2024
Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/tale-two-falls
The Cases
Case #1: A 79-year-old woman with a history of impaired cognition at baseline was brought from a skilled
nursing facility to the emergency department (ED) f…
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psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
November 01, 2012 - Defensive Medicine: "Glowing" with Pain
Citation Text:
Sethi MK. Defensive Medicine: "Glowing" with Pain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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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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Format:
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psnet.ahrq.gov/web-mm/chemotherapy-extravasation
September 24, 2010 - Chemotherapy Extravasation
Citation Text:
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.122_slideshow.ppt
April 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case April 2006
Is the “Surgical Personality” a Threat to Patient Safety?
Source and Credits
This presentation is based on the April 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary …
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psnet.ahrq.gov/node/33572/psn-pdf
December 15, 2024 - Checklists
December 15, 2024
Checklists. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/checklists
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Background
…
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psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - In the case of promoting vaginal birth, it is important to understand how C-section rates
impact maternal
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psnet.ahrq.gov/web-mm/weighing-surgical-safety
August 04, 2021 - August 10, 2019
Perspective
Innovations in Promoting
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Promoting
physician well-being is a new aspect of systems-based practice and professionalism that is
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - physicians at the initial hospital also allows those physicians to take
responsibility and apologize, promoting
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psnet.ahrq.gov/node/33865/psn-pdf
September 01, 2018 - more educated might find it easier to
understand, access, and use those electronic health records for promoting