-
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…
-
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…
-
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…
-
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…
-
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…
-
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…
-
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…
-
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…
-
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 …
-
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 …
-
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…
-
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…
-
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…
-
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…
-
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 …
-
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…
-
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…
-
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…
-
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…
-
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…