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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - Improving Diagnostic Safety and Quality
April 26, 2023
Al-Khafaji J, Lee M, Mossburg S. Improving Diagnostic Safety and Quality . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
Introduction
During an annual editorial review of featured articles in the Agency for …
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - Delay in Appropriate Diagnosis and Treatment Leading to
Death from Pulmonary Embolism
February 10, 2021
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary
Embolism. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leadi…
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psnet.ahrq.gov/node/851568/psn-pdf
July 31, 2023 - A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion
July 31, 2023
Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomid…
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psnet.ahrq.gov/node/74022/psn-pdf
March 01, 2021 - The Role of Community Pharmacists in Patient Safety
October 25, 2021
Luchen GG, Hall KK, Hough KR. The Role of Community Pharmacists in Patient Safety . PSNet [internet].
2021.
https://psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
What is a community pharmacy?
Community pharmacies are somet…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
July 01, 2011 - Spotlight Case July 2008
Spotlight Case
Watch the Warfarin!
1
2
Source and Credits
This presentation is based on the July 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Raman Khanna, MD, and Margaret Fang, MD, MPH; University of California, Sa…
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psnet.ahrq.gov/node/73905/psn-pdf
October 06, 2021 - Health Equity and Maternal Health
October 6, 2021
Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/health-equity-and-maternal-health
Redefining Maternal Safety
Maternal safety refers to the safety of a person during pregnancy, childb…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.356_slideshow.ppt
September 01, 2015 - PowerPoint Presentation
Spotlight
Abdominal Pain in Early Pregnancy
This presentation is based on the September 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Charlie C. Kilpatrick, MD, Associate Professor of Obstetrics and Gynecology, Baylor …
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psnet.ahrq.gov/node/33617/psn-pdf
August 01, 2005 - In Conversation with…Barbara A. Blakeney, MS, RN
August 1, 2005
In Conversation with…Barbara A. Blakeney, MS, RN. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
Editor's Note: Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses
Associa…
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psnet.ahrq.gov/node/33790/psn-pdf
August 01, 2015 - New Insights on Safety and Health IT
August 1, 2015
Hettinger ZA, Ratwani RM, Fairbanks RJ. New Insights on Safety and Health IT. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
Perspective
Despite the widespread adoption of electronic health records (EHRs) over the las…
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psnet.ahrq.gov/node/33606/psn-pdf
December 15, 2024 - Opioid Safety
December 15, 2024
Opioid Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/opioid-safety
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…
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psnet.ahrq.gov/node/33753/psn-pdf
August 22, 2013 - Update on Safety Culture
August 22, 2013
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/update-safety-culture
Perspective
Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians
treat each other with r…
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psnet.ahrq.gov/node/49759/psn-pdf
May 01, 2016 - Falling Through the Crack (in the Bedrails)
May 1, 2016
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
Case Objectives
Review the epidemiology of patient falls and associated injuries in the hospital set…
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psnet.ahrq.gov/node/853081/psn-pdf
August 30, 2023 - In Conversation with... Kathleen Sanford and Sue
Schuelke about Virtual Nursing
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. In Conversation with.. Kathleen Sanford and Sue Schuelke about
Virtual Nursing. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schue…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/node/49597/psn-pdf
February 01, 2010 - Adolescent Diabetes: A Routine Visit?
February 1, 2010
Slap GB. Adolescent Diabetes: A Routine Visit? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
Case Objectives
Appreciate the increasing prevalence of obesity and type 2 diabetes mellitus (T2DM) among
adolescents in the…
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psnet.ahrq.gov/node/49537/psn-pdf
June 01, 2007 - Beeline to Spine
June 1, 2007
Smetana GW. Beeline to Spine. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/beeline-spine
Case Objectives
Understand the elements of preoperative medical evaluation.
Appreciate the limited role for preoperative laboratory testing.
Appreciate the importance of communication a…
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psnet.ahrq.gov/node/49682/psn-pdf
April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature
Closure and Anchoring in a Complicated Case
April 1, 2013
Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a
Complicated Case. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…
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psnet.ahrq.gov/node/843051/psn-pdf
February 01, 2023 - Respiratory Distress after Neck Surgery: Two Cases of
Postoperative Cervical Hematoma.
February 1, 2023
Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical
Hematoma. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/node/843150/psn-pdf
December 05, 2022 - In Conversation with... Connor Wesley, RN, BSN on
Patient Safety Concerns and the LGBTQ+ Population
February 1, 2023
In Conversation with.. Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-connor-wesley-rn-bsn-patie…