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psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage
January 15, 2020 - Newspaper/Magazine Article
Proactive prevention of maternal death from maternal hemorrhage.
Citation Text:
Proactive prevention of maternal death from maternal hemorrhage. Quick Safety. October 29, 2019;(51):1-3.
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psnet.ahrq.gov/issue/american-hospital-association-mckesson-quest-quality-prize
September 23, 2020 - Award Recipient
American Hospital Association-McKesson Quest for Quality Prize.
Citation Text:
American Hospital Association-McKesson Quest for Quality Prize. Jt Comm J Qual Patient Saf. 2006;32(10):541-572.
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psnet.ahrq.gov/issue/aorn-guidance-statement-creating-patient-safety-culture
March 14, 2018 - Organizational Policy/Guidelines
AORN guidance statement: creating a patient safety culture.
Citation Text:
Nurses A of periOR. AORN guidance statement: creating a patient safety culture. AORN journal. 2006;83(4):936-42.
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psnet.ahrq.gov/issue/pediatric-medication-errors-and-reduction-strategies-perioperative-period
October 19, 2022 - Review
Pediatric medication errors and reduction strategies in the perioperative period.
Citation Text:
Pediatric medication errors and reduction strategies in the perioperative period. Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.
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psnet.ahrq.gov/issue/preventing-cathetertubing-misconnections-much-needed-help-way
May 07, 2018 - Newspaper/Magazine Article
Preventing catheter/tubing misconnections: much needed help is on the way.
Citation Text:
Preventing catheter/tubing misconnections: much needed help is on the way. ISMP Medication Safety Alert! Acute care edition! July 15, 2010;15:1-2.
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psnet.ahrq.gov/issue/managing-can-improve-teamwork-or
September 23, 2020 - Commentary
"Managing up" can improve teamwork in the OR.
Citation Text:
Smith SL. "Managing up" can improve teamwork in the OR. AORN J. 2010;91(5):576-82. doi:10.1016/j.aorn.2009.08.014.
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psnet.ahrq.gov/issue/handoffs-and-fumbles
June 12, 2007 - Book/Report
Handoffs and fumbles.
Citation Text:
Handoffs and fumbles. Wachter RM, Shojania KG. Chapter in: Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land, LLC; 2004.
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psnet.ahrq.gov/issue/paradoxes-defensive-medicine
June 08, 2022 - Commentary
The paradoxes of defensive medicine.
Citation Text:
The paradoxes of defensive medicine. Saks MJ, Landsman S. Health Matrix: J Law-Med. 2020;30(1):25-84.
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psnet.ahrq.gov/issue/world-patient-safety-science-technology-summit
January 01, 2020 - Meeting/Conference Proceedings
World Patient Safety, Science & Technology Summit.
Citation Text:
World Patient Safety, Science & Technology Summit. Patient Safety Movement Foundation. VEA Newport Beach, Newport Beach, CA, June 1-2, 2023.
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - SPOTLIGHT CASE
An Ounce of Prevention
Citation Text:
Kucher N. An Ounce of Prevention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
February 26, 2025 - In Conversation with...Albert Wu, MD, MPH
July 1, 2008
Citation Text:
In Conversation with..Albert Wu, MD, MPH. PSNet [internet]. 2008.In Conversation with...Albert Wu, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication
Breakdown.
August 30, 2023
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Spotlight
Missed Opportunities for Suicide
Risk Assessment
Source and Credits
• This presentation is based on the November 2019 AHRQ WebM&M
Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Glen Xiong, MD & Debra Kahn, MD
○ Editors in Chief, AHRQ We…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - PowerPoint Presentation
Spotlight
A Lot of Pain (Medications)
1
This presentation is based on the September 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Mother's Milk, but Whose Mother?
Citation Text:
Dougherty D. Mother's Milk, but Whose Mother?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
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psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
March 27, 2024 - In Conversation With… Suchi Saria, PhD
July 1, 2019
Citation Text:
In Conversation With… Suchi Saria, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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