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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program?
Ian Scott, MBBS, MHA, MEd | March 1, 2015
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety …
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - 2010
Perspective
ACGME's 2017 Revision of Common Program Requirements
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - Dual Therapy Debacle
Citation Text:
Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
June 24, 2020 - SPOTLIGHT CASE
Fatal Error in Neonate: Does "Just Culture" Provide an Answer?
Citation Text:
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. 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/33773/psn-pdf
September 01, 2014 - Overuse as a Patient Safety Problem
September 1, 2014
Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem
Perspective
Nearly half of primary care physicians in the United States believe that patients cared for in their own
prac…
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…
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psnet.ahrq.gov/node/49405/psn-pdf
June 01, 2003 - XL or Smaller?
June 1, 2003
Kozer E. XL or Smaller? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/xl-or-smaller
The Case
With a history of hypertension and chronic renal failure secondary to hemolytic uremia syndrome at age 3,
a 14-year-old boy presented to the emergency department with dehydration second…
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psnet.ahrq.gov/node/49631/psn-pdf
July 01, 2011 - Patient Safety and Adherence to Self-Administered
Medications
July 1, 2011
Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications.
PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
The Case
A 30-year-o…
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psnet.ahrq.gov/node/73412/psn-pdf
August 01, 2022 - “Behavioral Health Vital Signs” Initiative Increases Patient
Education and Disclosure about Interpersonal Violence
(IPV)
June 30, 2021
https://psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-
disclosure
Summary
The Behavioral Health Vital Signs (BHVS) screener i…
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psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - Turn the Other Cheek
March 1, 2012
Starling J. Turn the Other Cheek. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/turn-other-cheek
The Case
A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy
was diagnostic for squamous cell carcinoma (SCC) and docume…
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…
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psnet.ahrq.gov/node/33797/psn-pdf
January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety
Science, Policy, and Practice
January 1, 2016
Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet
[internet]. 2016.
https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…
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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
April 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case April 2008
Antibiotics for URI/Sinusitis: A Simple Decision Gone Bad
Source and Credits
This presentation is based on the April 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sumant Ranji, MD,…
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psnet.ahrq.gov/node/49556/psn-pdf
March 01, 2008 - Hold That Order
March 1, 2008
Grissinger M. Hold That Order. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/hold-order
The Case
A 25-year-old woman with a history of a pituitary tumor was admitted with hypernatremia. Because of her
previous pituitary resection and radiation, the patient had a long history …
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psnet.ahrq.gov/node/33676/psn-pdf
November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH
November 1, 2008
In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
Editor's note: Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann
Arbor VA …
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psnet.ahrq.gov/node/49515/psn-pdf
July 01, 2006 - Over Not So Easy
July 1, 2006
Cucina R. Over Not So Easy. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/over-not-so-easy
The Case
A 62-year-old woman with end-stage liver disease was hospitalized for recurrent variceal bleeding. On
admission, she reported allergies to a number of medications as well as a …
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psnet.ahrq.gov/node/49551/psn-pdf
December 01, 2007 - Too Hot For Comfort
December 1, 2007
Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/too-hot-comfort
The Case
A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV
antibiotics via a peripheral line in the left antec…