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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Acute care clinicians must be able to recognize clinical cues quickly and
completely, detect patterns
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psnet.ahrq.gov/node/33792/psn-pdf
September 01, 2015 - Certainly in the hospital
world, we recognize that we're over-alerting people and folks have begun tuning
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - Recognize the importance of performing an unbiased and individualized assessment of risks and benefits
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - Some institutions recognize concomitant use of 5 or more prescription drugs
(excluding over-the-counter
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - Recognize the risk of occult hand tendon injuries.
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psnet.ahrq.gov/webmm/submit-case
Submit a Case
Note that your name will not be publicly associated with the case
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Case Form
The content of case submissions is anonymous. Do not provide any personally identifiable (patient or provider) information, and do not use institution…
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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/patient-mix
December 01, 2007 - Patient Mix-Up
Citation Text:
Shojania KG. Patient Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model
to Advance Patient Safety in Care Transitions
November 16, 2022
Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to
Advance Patient Safety in Care Transitions . PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspecti…
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psnet.ahrq.gov/node/865418/psn-pdf
March 27, 2024 - Cybersecurity and How to Maintain Patient Safety
March 27, 2024
Pelletreau B, Riggi J, Gale B, et al. Cybersecurity and How to Maintain Patient Safety. PSNet [internet].
2024.
https://psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
Introduction
The integration of information technology (I…
-
psnet.ahrq.gov/node/49788/psn-pdf
March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A
Pharmacist Intervention
March 1, 2017
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
The Case
A 48-year…
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Two Wrongs Don't Make a Right (Kidney)
March 1, 2015
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
Case Objectives
Review the current definition of wrong-site surgery.
Describe the incidence of wrong-site surgery, and the…
-
psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/node/865467/psn-pdf
March 27, 2024 - I Just Want to Go Home: Understanding Delirium’s Impact
on Treatment Preferences
March 27, 2024
Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferenc…
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psnet.ahrq.gov/node/49782/psn-pdf
January 01, 2017 - A Potent Medication Administered in a Not So Viable
Route
January 1, 2017
Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
The Case
A 55-year-old man with history of nonischemic cardiomyop…
-
psnet.ahrq.gov/node/49596/psn-pdf
December 01, 2009 - Round-Trip Service
December 1, 2009
McGrath MH. Round-Trip Service. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/round-trip-service
The Case
A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms
in his left knee. He was referred by his primary care provid…
-
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/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
January 01, 2015 - PowerPoint Presentation
Spotlight
Monitoring Fetal Health
1
This presentation is based on the January 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Mark W. Scerbo, PhD, Department of Psychology, Old Dominion University, and Alfred Z. Abuham…
-
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…