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  1. psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
    February 12, 2020 - Diagnostic Overshadowing Dangers Citation Text: Raven MC. Diagnostic Overshadowing Dangers. 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 EndNote 7 XML E…
  2. psnet.ahrq.gov/web-mm/departure-central-line-ritual
    October 13, 2018 - Departure From Central Line Ritual Citation Text: Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndN…
  3. psnet.ahrq.gov/web-mm/chemotherapy-extravasation
    September 24, 2010 - Chemotherapy Extravasation Citation Text: Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50769/psn-pdf
    February 15, 2017 - Cultural Competence and Patient Safety December 27, 2019 Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety Background   Culture can be defined as the “personal identification, language, thoughts, co…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49411/psn-pdf
    July 01, 2003 - Code Status Confusion July 1, 2003 Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/code-status-confusion Case Objectives Appreciate challenges of determining goals of care in hospitalized patients Understand patients’ common misconceptions about CPR List typical mist…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49470/psn-pdf
    December 01, 2004 - Discharge Fumbles December 1, 2004 Forster AJ. Discharge Fumbles. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/discharge-fumbles Case Objectives List the types of adverse events that occur at discharge Identify the characteristics that identify patients at high risk for errors at discharge Understand th…
  7. psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
    November 08, 2013 - Diffusion of Responsibility Leads to Danger Citation Text: Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49475/psn-pdf
    March 01, 2005 - Techno Trip March 1, 2005 Cook RI. Techno Trip. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/techno-trip The Case A 70-year-old woman was admitted to a community hospital after developing confusion and right-sided weakness. A CT scan of her brain showed an acute subdural hematoma. The hospital arranged a…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33788/psn-pdf
    June 01, 2015 - In Conversation With… Christine Cassel, MD June 1, 2015 In Conversation With… Christine Cassel, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-christine-cassel-md Editor's note: Christine Cassel, MD, is President and CEO of the National Quality Forum (NQF). Dr. Cassel, one of the foun…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33743/psn-pdf
    December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit December 1, 2012 Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit. PSNet [internet]. 2012. https://psnet.ahrq.gov…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49513/psn-pdf
    July 01, 2006 - Moving Pains July 1, 2006 Schell H, Wachter R. Moving Pains. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/moving-pains Case Objectives Appreciate the risk posed by intrahospital transport Identify key features of current transport practice and policies Propose interventions that might improve safety of …
  12. psnet.ahrq.gov/web-mm/real-heartache
    October 01, 2018 - A Real Heartache Citation Text: Polevoi SK. A Real Heartache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49461/psn-pdf
    September 01, 2004 - Reaction to Dye September 1, 2004 Cohan R. Reaction to Dye. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/reaction-dye The Case A patient was referred to urology after having several episodes of gross hematuria. The urologist thought that the patient might have a renal mass and sent him to radiology for a…
  14. Psn-Pdf (pdf file)

    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…
  15. 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…
  16. psnet.ahrq.gov/web-mm/wrong-channel
    February 01, 2003 - The Wrong Channel Citation Text: Gosbee JW. The Wrong Channel . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
  17. psnet.ahrq.gov/primer/patient-safety-indicators
    June 15, 2024 - Patient Safety Indicators Citation Text: Tokareva I, Romano P. Patient Safety Indicators.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33795/psn-pdf
    November 01, 2015 - Introducing the Redesigned AHRQ Patient Safety Network November 1, 2015 Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network Editorial It's hard to believe that it has been 15 years since th…
  19. psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
    January 01, 2020 - Spotlight The Lost Start Date, an Unknown Risk of E-prescribing Source and Credits • This presentation is based on the October 2019 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm ○ CME credit is available • Commentary by: Adam Wright, PhD, and Gordon Schiff, MD ○ Editor, AHRQ…
  20. Spotlight Case (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
    October 01, 2009 - Spotlight Case Spotlight Case Difficult Encounters: A CMO and CNO Respond Source and Credits This presentation is based on the October 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Ernie Ring, MD; Jane Hirsch, RN, MS UCSF Medical Cen…

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