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psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…
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psnet.ahrq.gov/node/33624/psn-pdf
December 01, 2005 - In Conversation with…Troyen A. Brennan, MD, JD, MPH
December 1, 2005
In Conversation with…Troyen A. Brennan, MD, JD, MPH. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
Dr. Robert Wachter, Editor, AHRQ WebM&M: What got you interested in the law and its interface…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-200-section-6-b-expert-workgroup.pdf
September 18, 2014 - Section 6-B, Expert Workgroup Roster and Materials
…
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
…
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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psnet.ahrq.gov/node/49815/psn-pdf
December 01, 2017 - Over-the-Counter Oversight
December 1, 2017
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/over-counter-oversight
The Case
A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although
portions of his skin we…
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psnet.ahrq.gov/periodic-issue/periodic-issue-472
February 26, 2025 - February 26, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, repor…
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psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
February 17, 2021 - Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls
Citation Text:
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departme…
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psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
April 28, 2021 - Procedural Mishap: Learning Curve?
Citation Text:
Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
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www.ahrq.gov/sites/default/files/publications/files/workforce_executive_summary_0.pdf
October 01, 2016 - AHRQ New Models of Primary Care Workforce and Financing - Executive Summary
New Models of Primary Care
Workforce and Financing
Executive Summary
AHRQ New Models of Primary Care Workforce and
Financing
Executive Summary
Prepared for:
Agency for Healthcare Research and …
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psnet.ahrq.gov/node/49776/psn-pdf
November 01, 2016 - Continuity Errors in Resident Clinic
November 1, 2016
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
The Case
A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty
concentrating. …
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psnet.ahrq.gov/node/33685/psn-pdf
May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA
May 1, 2009
In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and
Family M…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.182_slideshow.ppt
September 01, 2008 - Spotlight Case July 2008
Spotlight Case
Empiric Steroids: the Good, the Bad, and the Ugly
Source and Credits
This presentation is based on the September 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Edward D. Harris, Jr, MD, Stanford U…
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psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
February 01, 2003 - The Unintended Consequences of Florida Medical Liability Legislation
Paul Barach, MD, MPH | December 1, 2005
View more articles from the same authors.
Citation Text:
Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet].…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-234-headaches-pregnancy-summary.pdf
November 01, 2020 - Comparative Effectiveness Review No. 234 Evidence Summary: Management of Primary Headaches in Pregnancy
Comparative Effectiveness Review
Number 234
Management of Primary Headaches
in Pregnancy
Evidence Summary
Main Points
• Prevention of primary headache in women who are pregnant (or attempting to
become pre…
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psnet.ahrq.gov/print/pdf/node/74277
January 01, 2021 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Medication/Drug Errors
Curated Library
Primers
Medication Administration Errors
Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March,
12 2021
Medication administration errors are a persistent patient saf…
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cdsic.ahrq.gov/sites/default/files/2025-07/CDSiC%20Topic%20Highlight_PC%20CDS%20and%20SDM_508_0.pdf
January 01, 2025 - How Patient-Centered Clinical Decision Support Can Strengthen Shared Decision Making
AHRQ Pub. No. 25-0058
June 2025
How Patient-Centered Clinical Decision Support
Can Strengthen Shared Decision Making
This resource describes shared decision making, patient-centered clinical decision support (PC…
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - The Dangerous Detour
Citation Text:
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/ambulatory/6bb-toolkit-monitor.pdf
April 20, 2021 - Six Building Blocks How-To-Implement Toolkit: Monitor and Sustain Guide
Table of Contents
Introduction ......................................................................................................................................1
What Is the Monitor and Sustain Guide?....................................…