-
psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - about this question of whether there should be certified experts in safety, or this should be a generic skill
-
psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
March 01, 2018 - Investigations revealed that nurse staffing levels and skill mix had been changed at the hospital, without
-
psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - The collateral history: an overlooked core clinical skill. Eur Geriatr Med. 2020;11(6):1003–1007.
-
psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - weaknesses may include lack of care protocols &
algorithms, less than optimal team membership and/or skill
-
psnet.ahrq.gov/node/864867/psn-pdf
April 10, 2024 - The collateral history: an overlooked core clinical skill. Eur
Geriatr Med. 2020;11(6):1003–1007.
-
psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
December 18, 2024 - The collateral history: an overlooked core clinical skill.
-
psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
-
psnet.ahrq.gov/node/49393/psn-pdf
April 01, 2003 - Which End Is Which?
April 1, 2003
Campbell AR. Which End Is Which? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/which-end-which
The Case
A 39-year-old woman with chronic peri-anal fistulas and infected anal sinuses underwent laparoscopic
diverting colostomy to divert her fecal stream and allow the perine…
-
psnet.ahrq.gov/node/49439/psn-pdf
March 01, 2004 - Lethal Cap
March 1, 2004
Schillinger D. Lethal Cap. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-cap
The Case
A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to
have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
November 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfusion Overload
1
2
Source and Credits
This presentation is based on the November 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …
-
psnet.ahrq.gov/node/49404/psn-pdf
June 01, 2003 - Not a Miscarriage
June 1, 2003
Learman LA. Not a Miscarriage. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/not-miscarriage
The Case
A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented
at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…
-
psnet.ahrq.gov/node/49842/psn-pdf
September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric
Emergency Equipment
September 1, 2018
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet
[internet]. 2018.
https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
The Case
As part of…
-
psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
-
psnet.ahrq.gov/node/33868/psn-pdf
October 01, 2018 - Safety in the Retail Pharmacy
October 1, 2018
Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-retail-pharmacy
Perspective
There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each
year.(1) Many patients interact w…
-
psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - National Patient Safety Goals
Citation Text:
Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - PowerPoint Presentation
Spotlight
Harm From Alarm Fatigue
This presentation is based on the December 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San …
-
psnet.ahrq.gov/node/72737/psn-pdf
February 09, 2021 - Geisinger’s Outpatient Addiction Medicine Specialty
Program Uses Data-Driven Decision Making and MAT to
Reduce Mortality Rates
February 9, 2021
https://psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-
driven-decision
Summary
The team at Geisinger sought to develop a…
-
psnet.ahrq.gov/perspective/patient-engagement-safety
January 01, 2018 - Annual Perspective
Patient Engagement in Safety
Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2017
View more articles from the same authors.
Citation Text:
Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. Rockville (MD): Agency…
-
psnet.ahrq.gov/node/60241/psn-pdf
February 24, 2022 - Coronavirus Disease 2019 (COVID-19) and Safety of Older
Adults Residing in Nursing Homes
February 24, 2022
Bakerjian D. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing
Homes. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-…
-
psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
September 01, 2014 - In Conversation With… Rosemary Gibson, MSc
September 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…