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psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
December 21, 2018 - Supplemental Items include condition-specific data collection with the goal to increase standardization
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psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading
to Multiple Complications and Operations
September 25, 2024
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications
and Operations. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
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psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
March 01, 2012 - We didn't need a court to answer, "Was our care reasonable, and did it meet our standards under the circumstances
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psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
March 01, 2012 - We didn't need a court to answer, "Was our care reasonable, and did it meet our standards under the circumstances
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - However, they undermine standardization and blur the effects of specific interventions or mask systemic
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psnet.ahrq.gov/node/49562/psn-pdf
May 01, 2008 - the nurse, but was also told that the nursing staff
would be establishing new guidelines to ensure standardization
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psnet.ahrq.gov/node/49764/psn-pdf
June 01, 2016 - Communication With Consultants
June 1, 2016
Cohn SL. Communication With Consultants. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/communication-consultants
The Case
A 30-year-old pregnant woman presented to the emergency department (ED) with nausea, headaches, and
fevers. Her laboratory studies were nota…
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psnet.ahrq.gov/node/33612/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—I. The Dana-Farber Cancer Institute Experience
May 1, 2005
Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber
Cancer Institute Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/organizat…
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psnet.ahrq.gov/node/49800/psn-pdf
July 01, 2017 - The Hidden Harms of Hand Sanitizer
July 1, 2017
Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
The Case
A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital
for community-acquired pn…
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psnet.ahrq.gov/node/49418/psn-pdf
October 01, 2003 - Charcoal Lavage of the Lungs
October 1, 2003
Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
The Case
A 47-year-old man presented to an emergency department (ED) with altered mental status, and was
believed to have a probable overdose. He receiv…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
May 01, 2011 - Spotlight Case July 2008
Spotlight Case
Duty to Disclose Someone Else’s Error
*
*
Source and Credits
This presentation is based on the May 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas H. Gallagher, MD University of Washington
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.365_slideshow.ppt
January 01, 2016 - PowerPoint Presentation
Spotlight
A Room Without Orders
1
This presentation is based on the January 2016
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Amy Vogelsmeier, PhD, RN, Sinclair School of Nursing; and Laurel Despins, PhD, RN, Sinclair Sc…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
February 01, 2018 - PowerPoint Presentation
Spotlight
Signout Fallout
1
Source and Credits
This presentation is based on the February 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.221_slideshow.ppt
July 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Weighing in on Surgical Safety
*
*
Source and Credits
This presentation is based on the July 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jay B. Brodsky, MD, Stanford University Medical Cente…
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psnet.ahrq.gov/primer/pharmacists-role-medication-safety
March 14, 2018 - Pharmacist's Role in Medication Safety
Citation Text:
The Pharmacist's Role in Medication Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7…
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psnet.ahrq.gov/node/50858/psn-pdf
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
Definition of Artificial Intelligence
The definition of artificial intelligence (…
-
psnet.ahrq.gov/primer/diagnostic-errors
June 15, 2024 - Diagnostic Errors
Citation Text:
Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
-
psnet.ahrq.gov/node/33570/psn-pdf
June 15, 2024 - Diagnostic Errors
June 15, 2024
Diagnostic Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/diagnostic-errors
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 20…
-
psnet.ahrq.gov/primer/falls
October 27, 2021 - Falls
Citation Text:
Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Citation
…
-
psnet.ahrq.gov/node/33586/psn-pdf
December 15, 2024 - Alert Fatigue
December 15, 2024
Alert Fatigue. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/alert-fatigue
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…