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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Did We Forget Something?
September 1, 2003
Gibbs VC. Did We Forget Something? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/did-we-forget-something
The Case
A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially
attributed to ventilator-associated pneumo…
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psnet.ahrq.gov/node/49389/psn-pdf
February 01, 2003 - Procedural Mishap: Learning Curve?
February 1, 2003
Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
The Case
A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had
undesired fert…
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hcup-us.ahrq.gov/db/vars/mdid_s/nisnote.jsp
September 01, 2008 - Healthcare Cost and Utilization Project (HCUP) NIS Notes
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs…
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hcup-us.ahrq.gov/reports/factsandfigures/2007/exhibit3_2.jsp
January 01, 2007 - Facts and Figures Exhibit 3.2
An official website of the Department of Health & Human Services
Search All AHRQ Websites
Careers
Contact Us
Espanol
FAQs
Email Updates
…
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psnet.ahrq.gov/node/33689/psn-pdf
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary,
Promoter of Patient Safety
October 1, 2009
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
Perspective
…
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cds.ahrq.gov/sites/default/files/cds/artifact/logic/2024-08/StatinTherapyForThePreventionAndTreatmentOfCVDeCQMDerived_Change_Log.txt
January 01, 2024 - =============================================================================================
StatinTherapyForThePreventionAndTreatmentOfCVDeCQMDerived Change Log
=============================================================================================
The following CQL downloads are currently available on CDS Con…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/NZcLsqV-5K7hyfot-qHQp9
November 01, 2004 - Screening for Bladder Cancer: A Brief Evidence Update
Epidemiology
The incidence of bladder cancer in the United
States in the year 2000 was approximately 21 per
100,000 persons.3 The American Cancer Society
estimates that 60,240 new cases of bladder cancer
will be diagnosed in the United States during 2004
(about 4…
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psnet.ahrq.gov/node/49727/psn-pdf
March 01, 2015 - Critical Opportunity Lost
March 1, 2015
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/critical-opportunity-lost
The Case
A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She
reported eating a heavy dinner the pre…
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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - OR Peeping
March 1, 2004
Mackenzie CF. OR Peeping. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/or-peeping
The Case
A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete
spontaneous abortion (miscarriage).
At this community hospital, a new operating room (OR) su…
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psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
January 01, 2020 - Spotlight
Spotlight
Inpatient Stroke Management in a Patient
with Type 1 Diabetes and Home Insulin
Pump
Source and Credits
• This presentation is based on the October 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Berit B…
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psnet.ahrq.gov/node/33876/psn-pdf
August 01, 2018 - Building a Safety Program in a Vast Health Care Network
March 1, 2019
Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
Perspective
Background
As hospital-based health care in the United …
-
psnet.ahrq.gov/node/49414/psn-pdf
September 01, 2003 - Making Do
September 1, 2003
Bradley LD. Making Do. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/making-do
The Case
A 56-year-old female with dysfunctional uterine bleeding and possible retained intrauterine device (IUD)
was scheduled for elective hysteroscopy and dilation and curettage (D&C). Of note, sh…
-
psnet.ahrq.gov/node/49826/psn-pdf
April 01, 2018 - Air on the Side of Caution
April 1, 2018
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/air-side-caution
The Case
A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of
breath and chest pain. A decision was m…
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psnet.ahrq.gov/node/33659/psn-pdf
October 01, 2007 - Making Just Culture a Reality: One Organization's
Approach
October 1, 2007
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
Perspective
We've all been there...something goes wrong,…
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psnet.ahrq.gov/node/49742/psn-pdf
September 01, 2015 - A Fumbled Handoff to Inpatient Rehab
September 1, 2015
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
The Case
An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…
-
psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health
Care
August 1, 2009
Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
Perspective
Frontline health care providers are challen…
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - Computerized Provider Order Entry
Citation Text:
Computerized Provider Order Entry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
June 15, 2024 - Strategies and Approaches for Tracking Improvements in Patient Safety
Citation Text:
Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citat…
-
psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - Computerized Provider Order Entry
March 15, 2025
Computerized Provider Order Entry. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/computerized-provider-order-entry
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…
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psnet.ahrq.gov/primer/radiation-safety
September 15, 2024 - Radiation Safety
Citation Text:
Radiation Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downl…