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psnet.ahrq.gov/node/33882/psn-pdf
June 01, 2019 - Building a Safety Program Using Principles of Resilience
Engineering
June 1, 2019
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety Program Using Principles of Resilience Engineering.
PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
Persp…
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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…
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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…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.356_slideshow.ppt
September 01, 2015 - PowerPoint Presentation
Spotlight
Abdominal Pain in Early Pregnancy
This presentation is based on the September 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Charlie C. Kilpatrick, MD, Associate Professor of Obstetrics and Gynecology, Baylor …
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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…
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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. …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - Spotlight Case July 2008
Spotlight Case
Right Regimen, Wrong Cancer: Patient Catches Medical Error
*
*
Source and Credits
This presentation is based on the May 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph O. Jacobson, MD, MSc…
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psnet.ahrq.gov/node/33780/psn-pdf
July 01, 2015 - Safety and Medical Education
January 1, 2014
Ranji SR. Safety and Medical Education. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/safety-and-medical-education
Annual Perspective 2014
As the patient safety field has grown, so too has the appreciation for the need to improve safety in medical
educatio…
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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - Human Factors Engineering Can Teach You How to Be
Surprised Again
November 1, 2006
Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
Perspective
Certain phrases ar…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/node/33755/psn-pdf
September 01, 2013 - What We've Learned About Leveraging Leadership and
Culture to Affect Change and Improve Patient Safety
September 1, 2013
Singer SJ. What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve
Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/what-weve-learned-ab…
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psnet.ahrq.gov/primer/surgical-site-infections
December 15, 2024 - Surgical Site Infections
Citation Text:
Surgical Site Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - Triggers and Trigger Tools
Citation Text:
Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/node/49658/psn-pdf
July 01, 2012 - Misleading Complaint
July 1, 2012
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/misleading-complaint
The Case
A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with
complaints of knee problems. The triage nurse docu…
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psnet.ahrq.gov/node/853774/psn-pdf
September 27, 2023 - One output factor, ED boarding, is recognized as having the
greatest impact on ED crowding and occurs
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psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
January 07, 2022 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers
Citation Text:
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/node/49597/psn-pdf
February 01, 2010 - Adolescent Diabetes: A Routine Visit?
February 1, 2010
Slap GB. Adolescent Diabetes: A Routine Visit? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
Case Objectives
Appreciate the increasing prevalence of obesity and type 2 diabetes mellitus (T2DM) among
adolescents in the…
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx
Spotlight
Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes
Source and Credits
• This presentation is based on the April 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/we…
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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - SPOTLIGHT CASE
"Do You Want Everything Done?": Clarifying Code Status
Citation Text:
Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
…
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - A Case of Mistaken Capacity: Why A Thorough
Psychosocial History Can Improve Care.
March 31, 2022
Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve
Care. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-c…