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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.110_slideshow.ppt
December 01, 2005 - Teamwork Survey
“Junior team members should not question the decisions made by senior team members”
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psnet.ahrq.gov/node/33856/psn-pdf
April 01, 2018 - Patient Safety During Hospital Discharge
April 1, 2018
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
Perspective
Patients are admitted to the hospital in the United States 35 million times per year.(1)…
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psnet.ahrq.gov/web-mm/overriding-considerations
March 09, 2009 - Overriding Considerations
Citation Text:
Holtzman NA. Overriding Considerations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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psnet.ahrq.gov/node/846935/psn-pdf
March 29, 2023 - Maternal Safety and Perinatal Mental Health
March 29, 2023
Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
Maternal patient safety is a critical aspect of healthcare given the complex pr…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/web-mm/medication-overdose
September 01, 2011 - Medication Overdose
Citation Text:
Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/node/49575/psn-pdf
November 01, 2008 - Sick and Pregnant
November 1, 2008
El-Ibiary S. Sick and Pregnant. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/sick-and-pregnant
The Case
A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty
breathing. The patient informed the staff that she was 17 weeks pre…
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psnet.ahrq.gov/node/49447/psn-pdf
June 01, 2004 - Dangerous Dapsone
June 1, 2004
Bookwalter T. Dangerous Dapsone. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/dangerous-dapsone
The Case
A 78-year-old woman with newly diagnosed multiple myeloma on corticosteroids presented to the
emergency department with dyspnea. Upon admission, she was found to be hypo…
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psnet.ahrq.gov/node/74242/psn-pdf
January 07, 2022 - The Next Step: Use of a Pre-Operative Checklist to
Prevent Missteps
January 7, 2022
Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
The Case
A 52-year-old woman w…
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psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
September 01, 2006 - Anesthesia: A Weighty Issue
Citation Text:
Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
October 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case October 2007
Do Not Disturb!
Source and Credits
This presentation is based on the October 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: F. Daniel Duffy, MD, University of Oklahoma, and…
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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - Inadvertent Castration
January 1, 2004
Calland FJ. Inadvertent Castration. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/inadvertent-castration
The Case
An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently
increased in size. The patient described persisten…
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psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-nursing
October 30, 2024 - ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay
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August 25, 2021
Innova…
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psnet.ahrq.gov/node/49854/psn-pdf
February 01, 2019 - Diagnostic Failure: The Growing Deficit
February 1, 2019
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
The Case
A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…
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psnet.ahrq.gov/node/49424/psn-pdf
November 01, 2003 - Waiting Too Long
November 1, 2003
Rosen MA. Waiting Too Long. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/waiting-too-long
The Case
A 31-year-old gravida 1, para 1 woman presented at 40 weeks in the early stages of labor having received
limited prenatal care at an outside clinic. Physical exam performed…
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psnet.ahrq.gov/node/49391/psn-pdf
February 01, 2003 - When "Psychiatric" Symptoms Are Not
February 1, 2003
Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
The Case
A 70-year-old man without documented past psychiatric history was placed on an involuntary hold as a
danger to oth…
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psnet.ahrq.gov/node/49616/psn-pdf
December 01, 2010 - Milliliters vs. Milligrams
December 1, 2010
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
The Case
A 32-year-old man was admitted to the hospital after a vehicle collision and multiple traumatic injuries. His
evaluation showed acu…
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psnet.ahrq.gov/node/33626/psn-pdf
January 01, 2006 - JB: That question—of "fixed" versus "formed" teams—comes up in both aviation and health care. … That's a teamwork question.
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psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
December 01, 2006 - RW: In the patient satisfaction survey world, the question, "would you recommend this hospital"? … Is there one safety culture, or climate, question that captures all of these individual variables? … And they all answer the question for themselves: Are you going to feel supported socially and emotionally … BS: That's a great question.
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - RW: In the patient satisfaction survey world, the question, "would you recommend this hospital"? … Is there one safety culture, or climate, question that captures all of these individual variables? … And they all answer the question for themselves: Are you going to feel supported socially and emotionally … BS: That's a great question.