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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49464/psn-pdf
    December 27, 2020 - Lap Burn October 1, 2004 Ball K. Lap Burn. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lap-burn The Case A woman was scheduled for an elective diagnostic laparoscopy for dysfunctional uterine bleeding. After accessing the abdomen with the trocar without complication, the surgeon inserted the laparoscope…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72616/psn-pdf
    December 22, 2020 - Adverse Events in Dentistry December 22, 2020 Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/adverse-events-dentistry Introduction Similar to many other healthcare settings, dentistry carries with it inherent patient safety risks. D…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33657/psn-pdf
    September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix September 1, 2007 Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix Perspective There is a slumbe…
  4. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.95_slideshow.ppt
    May 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case May 2005 Diagnosing Diagnostic Mistakes Source and Credits This presentation is based on the May 2005 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Robert McNutt, MD; Richard A…
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
    February 01, 2018 - PowerPoint Presentation Spotlight Signout Fallout 1 Source and Credits This presentation is based on the February 2018 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.221_slideshow.ppt
    July 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Weighing in on Surgical Safety * * Source and Credits This presentation is based on the July 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jay B. Brodsky, MD, Stanford University Medical Cente…
  7. psnet.ahrq.gov/primer/pharmacists-role-medication-safety
    March 14, 2018 - Pharmacist's Role in Medication Safety Citation Text: The Pharmacist's Role in Medication Safety. 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…
  8. psnet.ahrq.gov/primer/clinical-decision-support-systems
    December 15, 2024 - Clinical Decision Support Systems Citation Text: Clinical Decision Support Systems. 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 t…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836812/psn-pdf
    March 30, 2022 - Strategies and Approaches for Investigating Patient Safety Events March 30, 2022 Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events Background This primer provides a broad …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33603/psn-pdf
    September 15, 2024 - Surgical Site Infections September 15, 2024 Surgical Site Infections. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/surgical-site-infections PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33852/psn-pdf
    January 01, 2017 - Patient Engagement in Safety January 1, 2017 Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/patient-engagement-safety Annual Perspective 2017 Background In the past 2 decades, patient engagement in safety has evolved from obscurity to maturity. The Ins…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33586/psn-pdf
    December 15, 2024 - Alert Fatigue December 15, 2024 Alert Fatigue. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/alert-fatigue PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in 2024. Bac…
  13. psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
    February 01, 2011 - The University of Texas System Clinical Safety and Effectiveness Course Eric J. Thomas, MD, MPH; Jan Patterson, MD, MS; Sherry Martin, MEd; Doris Quinn, PhD; Gary Reed, MD; Ken Shine, MD | February 1, 2011  View more articles from the same authors. Citation Text: T…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60610/psn-pdf
    June 24, 2020 - Endometriosis: A Common and Commonly Missed and Delayed Diagnosis June 24, 2020 Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis   The Case A 15-year-old g…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72589/psn-pdf
    December 23, 2020 - Logo Delayed Breast Cancer Diagnosis: A False Sense of Security. December 23, 2020 Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security The Case A 60-year-old woman …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866826/psn-pdf
    September 25, 2024 - Hypoxic Gas Supply from Cross-Connected Pipelines September 25, 2024 Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines The Case An 8-year-old boy with no significant past medical…
  17. psnet.ahrq.gov/web-mm/consequences-medical-overuse
    May 05, 2021 - SPOTLIGHT CASE Consequences of Medical Overuse Citation Text: Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…
  18. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50754/psn-pdf
    December 18, 2019 - "Do You Want Everything Done?": Clarifying Code Status December 18, 2019 Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status Disclosure of Relevant Financial Relationships: As a p…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33787/psn-pdf
    January 01, 2018 - In Conversation With… Maureen Bisognano June 1, 2015 In Conversation With… Maureen Bisognano. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-maureen-bisognano Editor's note: Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement (IHI). We spoke with her about I…

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