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psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
September 01, 2025 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNe…
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Another Fall
April 1, 2003
Bogardus SG. Another Fall. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/another-fall
Case Objectives
List risk factors for falls in hospitalized patients
Understand appropriate use of restraints
Identify system issues contributing to falls in hospitalized patients
Case & Comm…
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psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
June 01, 2003 - SPOTLIGHT CASE
Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care
Citation Text:
Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
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psnet.ahrq.gov/web-mm/challenging-case-multiple-suicide-attempts-complex-patient-psychiatric-comorbidities
September 27, 2023 - SPOTLIGHT CASE
Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.
Citation Text:
Bourgeois JA, Xiong G. Challenging Case of Multiple Suicide Attempts in a Complex Patient with Psychiatric Comorbidities.. PSNet [internet]. Rockville (MD): Agency for …
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psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH
September 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Eric G. Poon, MD, MPH. 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/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case July 2004
Preventing Inappropriate Use of Novel Therapeutic Agents
Source and Credits
This presentation is based on the July 2004 AHRQ WebM&M Spotlight Case in Critical Care Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the W…
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - Late Anemia Following Rh Disease in a Newborn
Citation Text:
Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
Google Schola…
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - Discontinued Medications: Are They Really Discontinued?
Citation Text:
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. 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/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/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary …
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - The Wrongful Resuscitation
Citation Text:
Teno JM. The Wrongful Resuscitation. 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 tagged…
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psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
April 24, 2018 - The Fluidity of Diagnostic "Wet Reads"
Citation Text:
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/node/848037/psn-pdf
April 26, 2023 - A cluster randomized trial of two implementation
strategies to deliver audit and feedback in the EQUIPPED
medication safety program.
April 26, 2023
Vaughan CP, Burningham Z, Kelleher JL, et al. A cluster?randomized trial of two implementation strategies
to deliver audit and feedback in the EQUIPPED medication safe…
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psnet.ahrq.gov/node/43161/psn-pdf
December 12, 2014 - Burnout in the NICU setting and its relation to safety
culture.
December 12, 2014
Profit J, Sharek PJ, Amspoker AB, et al. Burnout in the NICU setting and its relation to safety culture. BMJ
Qual Saf. 2014;23(10):806-813. doi:10.1136/bmjqs-2014-002831.
https://psnet.ahrq.gov/issue/burnout-nicu-setting-and-its-rela…
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psnet.ahrq.gov/node/41223/psn-pdf
March 21, 2012 - High-profile investigations into hospital safety problems
in England did not prompt patients to switch providers.
March 21, 2012
Laverty AA, Smith PC, Pape UJ, et al. High-profile investigations into hospital safety problems in England
did not prompt patients to switch providers. Health Aff (Millwood). 2012;31(3):5…
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psnet.ahrq.gov/node/46068/psn-pdf
July 09, 2018 - A national survey assessing the number of records
allowed open in electronic health records at hospitals and
ambulatory sites.
July 9, 2018
Adelman JS, Berger MA, Rai A, et al. A national survey assessing the number of records allowed open in
electronic health records at hospitals and ambulatory sites. J Am Med In…
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psnet.ahrq.gov/node/38612/psn-pdf
May 06, 2009 - Assessing controlled substance prescribing errors in a
pediatric teaching hospital: an analysis of the safety of
analgesic prescription practice in the transition from the
hospital to home.
May 6, 2009
Lee BH, Lehmann CU, Jackson E, et al. Assessing controlled substance prescribing errors in a pediatric
teaching …
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psnet.ahrq.gov/node/46178/psn-pdf
December 22, 2017 - Evaluating serial strategies for preventing wrong-patient
orders in the NICU.
December 22, 2017
Adelman JS, Aschner JL, Schechter CB, et al. Evaluating Serial Strategies for Preventing Wrong-Patient
Orders in the NICU. Pediatrics. 2017;139(5). doi:10.1542/peds.2016-2863.
https://psnet.ahrq.gov/issue/evaluating-ser…
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psnet.ahrq.gov/node/42946/psn-pdf
January 07, 2015 - Evaluation of medium-term consequences of
implementing commercial computerized physician order
entry and clinical decision support prescribing systems in
two 'early adopter' hospitals.
January 7, 2015
Cresswell K, Bates DW, Williams R, et al. Evaluation of medium-term consequences of implementing
commercial compu…