-
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.
-
psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - April 8, 2020
Reconciling medications at admission: safe practice recommendations and
-
psnet.ahrq.gov/perspective/safety-retail-pharmacy
May 11, 2016 - Safety in the Retail Pharmacy
Michelle A. Chui, PharmD, PhD | October 1, 2018
View more articles from the same authors.
Citation Text:
Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departme…
-
psnet.ahrq.gov/node/841567/psn-pdf
December 14, 2022 - Measuring Patient Safety
December 14, 2022
Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/measuring-patient-safety
Following the landmark report To Err is Human: Building a Safer Health System, developed by the Institute
of Medicine in 1999, pa…
-
psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
April 01, 2003 - The Wild West: Patient Safety in Office-Based Anesthesia
Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD | May 1, 2006
View more articles from the same authors.
Citation Text:
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild…
-
psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - A Seasonal Care Transition Failure
July 1, 2011
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
The Case
A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine
resident—for routine follow-up…
-
psnet.ahrq.gov/node/49536/psn-pdf
May 01, 2007 - On the Other Hand
May 1, 2007
Henneman EA. On the Other Hand. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/other-hand
The Case
A young woman with Takayasu's arteritis presented to the hospital with severe abdominal pain. The patient
had been diagnosed with Takayasu's a decade earlier. The disease results…
-
psnet.ahrq.gov/node/49703/psn-pdf
March 01, 2014 - After-Visit Confusion
March 1, 2014
Ventres W. After-Visit Confusion. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/after-visit-confusion
The Case
An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white
spots near her tongue. The patient's mother accompanied her …
-
psnet.ahrq.gov/node/49484/psn-pdf
June 01, 2005 - Two Pills, Same Drug
June 1, 2005
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/two-pills-same-drug
The Case
A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past
medical history included several AIDS-related complica…
-
psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
-
psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - Departure From Central Line Ritual
May 1, 2015
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/departure-central-line-ritual
The Case
A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
-
psnet.ahrq.gov/node/49523/psn-pdf
November 01, 2006 - Urinary Retention Dilemma
November 1, 2006
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma
The Case
Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy
(BPH) and urinary hesitancy returned to th…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - PowerPoint Presentation
Spotlight
Errors in Sepsis Management
This presentation is based on the May 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF)
Editor, AHRQ WebM&M: Rober…
-
psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3
Citation Text:
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
-
psnet.ahrq.gov/node/49526/psn-pdf
December 01, 2006 - Crossing the Borderline
December 1, 2006
Oldham JM. Crossing the Borderline. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/crossing-borderline
The Case
A 24-year-old woman with borderline personality disorder was admitted to an inpatient psychiatry unit
following a failed suicide attempt with excess doses…
-
psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - CVC Removal: A Procedure Like Any Other
June 1, 2014
Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
The Case
A 27-year-old man with a history of Behçet disease and recurrent liver abscesses was admitted to the
hospital for a p…
-
psnet.ahrq.gov/node/33782/psn-pdf
March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety
Measurement Program?
March 1, 2015
Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? PSNet [internet].
2015.
https://psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
Perspective
Much…
-
psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - The Dropped Lung
May 1, 2003
Heffner JR. The Dropped Lung. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dropped-lung
The Case
A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been
hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
-
psnet.ahrq.gov/node/33823/psn-pdf
January 01, 2017 - Workplace Safety in Health Care
January 1, 2017
Simon RW, Canacari EG. Workplace Safety in Health Care. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/workplace-safety-health-care
Perspective
The patient safety movement has highlighted the risks that patients face when receiving health care. But,
impo…
-
psnet.ahrq.gov/node/49823/psn-pdf
March 01, 2018 - Shortcuts to Acetaminophen-induced Liver Failure
March 1, 2018
Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
The Case
An 18-year-old woman, 27 weeks pregnant, presented to the emergency dep…