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psnet.ahrq.gov/node/33683/psn-pdf
April 01, 2009 - Accreditation and Regulation: Can They Help Improve
Patient Safety?
April 1, 2009
Warburton RN. Accreditation and Regulation: Can They Help Improve Patient Safety? PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
Perspective
My grandfath…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - PowerPoint Presentation
Spotlight
Diagnostic Delay in the Emergency Department
1
Source and Credits
This presentation is based on the May 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Add-on Case and the Missing Checklist
Citation Text:
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/issue/premature-closure-not-so-fast
September 28, 2022 - Commentary
Premature closure? Not so fast.
Citation Text:
Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89. doi:10.1136/bmjqs-2016-005267.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - various members of the interprofessional team
during the transition, and the implementation of staggered start
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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Start
continuous infusion at 2 m
/kg/min.
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psnet.ahrq.gov/node/33696/psn-pdf
June 01, 2010 - If you start from the position that you're looking for aberrant presentations, or if you're aware of … PC: You must have a bit of a thick skin to start that.
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psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - Antiseizure Medication Disorder
May 1, 2007
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
Case Objectives
Appreciate the challenges of safe use of antiepileptic medications.
Identify phenytoin toxicity.
Understand the pharmaco…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
May 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer?
*
*
Source and Credits
This presentation is based on the May 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sidney W.A. Dekker, Ph…
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psnet.ahrq.gov/node/861838/psn-pdf
January 31, 2024 - Adverse Drug Event (ADE) Surveillance and Pharmacist
Counseling
January 31, 2024
https://psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
Summary
Adverse events resulting from medications are a common occurrence that often go undetected, unreported,
and unaddressed.1 The imp…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - senior leadership support
Secure commitment for resources for the project during its development
Start
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psnet.ahrq.gov/node/33649/psn-pdf
May 01, 2007 - And I did start to challenge these doctors' colleagues, who were usually protecting
their associates … Then
we can start to highlight areas where things are getting better.
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple
Health System Vulnerabilities
May 26, 2021
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health
System Vulnerabilities. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - SPOTLIGHT CASE
Antiseizure Medication Disorder
Citation Text:
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - various members of the interprofessional team during the transition, and the implementation of staggered start
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psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of
Pediatrics a…
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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - Errors in Sepsis Management
May 1, 2015
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/errors-sepsis-management
Case Objectives
Define sepsis, severe sepsis, and septic shock.
Describe the severe sepsis/septic shock resuscitation bundle.
Recognize commonly encou…
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psnet.ahrq.gov/node/49571/psn-pdf
October 01, 2008 - Coming Up Short
October 1, 2008
Hochberg Z'ev. Coming Up Short. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/coming-short
The Case
A 12-year-old Hispanic female was seen for a well-child check. The child was delivered 2 months
prematurely (likely due to domestic violence) in Puerto Rico. She had an intra…
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psnet.ahrq.gov/node/33642/psn-pdf
November 01, 2006 - In Conversation With...Donald A. Norman, PhD
November 1, 2006
In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you
become interested…