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psnet.ahrq.gov/node/33634/psn-pdf
May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia
May 1, 2006
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia.
PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
Perspective
Over the last decade, sur…
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - Risk Management and Patient Safety
December 1, 2010
Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety
Perspective
In 1990, a Harvard-based research team reported the incidence of medical errors …
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psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - One Dose, Fifty Pills
November 1, 2005
Smith L. One Dose, Fifty Pills . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/one-dose-fifty-pills
The Case
A middle-aged man was admitted to the medical service of a teaching hospital with suspected vasculitis.
When the initial diagnostic studies failed to provide …
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psnet.ahrq.gov/node/49589/psn-pdf
August 01, 2009 - Hiding in Plain Sight
August 1, 2009
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/hiding-plain-sight
The Case
A 65-year-old woman presented to an emergency department (ED) with 48 hours of nontraumatic left lower
back pain and general malaise. She was diagnosed with a …
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psnet.ahrq.gov/primer/electronic-health-records
March 15, 2025 - Electronic Health Records
Citation Text:
Electronic Health Records. 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 R…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
March 01, 2012 - Spotlight Case July 2008
Spotlight Case
Postdischarge Follow-Up Phone Call
*
*
Source and Credits
This presentation is based on the March 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Michelle Mourad, MD, and Stephanie Rennke, MD; Divi…
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psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx
Spotlight
When the Indications for Drug
Administration Blur
Source and Credits
• This presentation is based on the June 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Julia Munsch,…
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
…
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psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - Medication Errors and Adverse Drug Events
December 15, 2024
Medication Errors and Adverse Drug Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect cu…
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psnet.ahrq.gov/web-mm/which-end-which
February 09, 2011 - Which End Is Which?
Citation Text:
Campbell AR. Which End Is Which?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/864868/psn-pdf
March 27, 2024 - Inpatient Transitions of Care: Challenges and Safety
Practices
March 27, 2024
Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet].
2024.
https://psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
Background
Transitions of care occur …
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psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
January 01, 2008 - National speakers plus our own OB Task Force leadership presented the results and recommendations.
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psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
November 25, 2020 - enter critical information (including copying and pasting previous history from the EHR) and share recommendations
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries
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July 8, 2022
Innovation
Contact
…
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - SPOTLIGHT CASE
Some Patients Can't Wait: Improving Timeliness of Emergency Department Care
Citation Text:
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…
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psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
January 01, 2008 - National speakers plus our own OB Task Force leadership presented the results and recommendations.
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psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
February 01, 2014 - The Institute for Safe Medication Practices recently provided a number of practice recommendations for
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - April 8, 2020
Reconciling medications at admission: safe practice recommendations and
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psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
May 28, 2020 - have the authority to dictate how institutions may connect their electronic devices, they have issued recommendations
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - Preventive Services Task Force, which often must make recommendations in the face of insufficient evidence