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psnet.ahrq.gov/periodic-issue/periodic-issue-373
December 14, 2022 - January 11, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/periodic-issue/periodic-issue-383
March 15, 2023 - March 22, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/issue/empowering-patients-hospital-new-approach-reducing-burden-health-care-associated-infections
May 25, 2022 - Study
Empowering patients in the hospital as a new approach to reducing the burden of health care–associated infections: the attitudes of hospital health care workers.
Citation Text:
Seale H, Chughtai AA, Kaur R, et al. Empowering patients in the hospital as a new approach to reducing th…
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psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
February 01, 2004 - Renal Failure Due to Benign Prostatic Hyperplasia
Citation Text:
Barry MJ, Garnick MB. Renal Failure Due to Benign Prostatic Hyperplasia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google…
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psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
July 31, 2023 - Procedure Complications – Who is Responsible for Follow up?
Citation Text:
Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - SPOTLIGHT CASE
Right? Left? Neither!
Citation Text:
Chassin MR, Howell EA. Right? Left? Neither!. 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/primer/burnout
November 20, 2024 - Burnout
Citation Text:
Yellowlees P, Rea M. Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Do…
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - SPOTLIGHT CASE
Low on the Totem Pole
Citation Text:
Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
September 22, 2010 - Inappropriate Antibiotic Use
Citation Text:
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - Annual Perspective
Impact of System Failures on Healthcare Workers
George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD
| March 21, 2023
View more articles from the same authors.
Citation Text:
Zangaro G, Van CM, Mossburg S. Imp…
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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/web-mm/failure-latch
November 27, 2012 - Failure to Latch
Citation Text:
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…
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psnet.ahrq.gov/node/33805/psn-pdf
April 01, 2016 - In Conversation With… Thomas J. Nasca, MD, MACP
April 1, 2016
In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
Editor's note: Dr. Nasca is Chief Executive Officer of the Accreditation Council for Graduate Medical
Educat…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - Spotlight
Spotlight
Mistaken Attribution, Diagnostic Misstep
*
Source and Credits
This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD
…
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psnet.ahrq.gov/node/49437/psn-pdf
March 01, 2004 - Crossing the Line
March 1, 2004
Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/crossing-line
Case Objectives
Review complications of central venous catheterization
Discuss patient and operator factors that affect complication rates
Describe methods for preventing c…
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psnet.ahrq.gov/node/33822/psn-pdf
January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA
January 1, 2017
In Conversation With… Paul H. O'Neill, MPA. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
Editor's note: Mr. O'Neill served as the United States Secretary of the Treasury under President George
W. Bush and, prio…
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - Tough Call: Addressing Errors From Previous Providers
March 1, 2014
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
Case Objectives
Define what it means to be a professional.
Identi…
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…