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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
    January 01, 2023 - Spotlight Spotlight Prolonged DKA in Pregnancy: A Case of Communication Breakdown Source and Credits • This presentation is based on the August 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Sarah Marshall, MD and Nina M. …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33807/psn-pdf
    May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD May 1, 2016 In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd Editor's note: Dr. Drew, a nurse researcher, is the David Mortara Distinguished Professor of Physiological Nursing and…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49437/psn-pdf
    March 01, 2004 - Crossing the Line March 1, 2004 Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/crossing-line Case Objectives Review complications of central venous catheterization Discuss patient and operator factors that affect complication rates Describe methods for preventing c…

  4. Getting the Diagnosis Both Right and Wrong | PSNet

    psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
    May 29, 2024 - Getting the Diagnosis Both Right and Wrong Citation Text: Olson AP. Getting the Diagnosis Both Right and Wrong. 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…

  5. Continuing Education | PSNet

    psnet.ahrq.gov/continuing-education
    February 26, 2025 - Continuing Education What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…

  6. Innovations | PSNet

    psnet.ahrq.gov/innovations
    February 26, 2025 - Innovations The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49531/psn-pdf
    March 01, 2007 - Failure to Report March 1, 2007 Spath P. Failure to Report. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/failure-report Case Objectives List common causes of medical errors. Appreciate the magnitude of underreporting of adverse events. List the common barriers to reporting adverse events and near misses…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

  9. Root Cause Analysis Gone Wrong | PSNet

    psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

  10. When the Indications for Drug Administration Blur | PSNet

    psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
    May 26, 2021 - SPOTLIGHT CASE When the Indications for Drug Administration Blur Citation Text: Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation …

  11. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice | PSNet

    psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
    January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice Hardeep Singh, MD, MPH | January 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Singh H. Diagnostic Errors: A New Chapter in Patient Safe…

  12. Delayed Diagnosis of Mesenteric Ischemia | PSNet

    psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
    March 31, 2021 - support the diagnostic process, with improved feedback via error reporting systems and health information technology

  13. Hidden Heparins: HIT Happens | PSNet

    psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
    March 27, 2024 - hospitalized patients: implications for clinical practice and the potential use of healthcare information technology

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848107/psn-pdf
    April 26, 2023 - Many organizations have committed to continuous quality improvement with peer input and the use of technology

  15. Dropping to New Lows | PSNet

    psnet.ahrq.gov/web-mm/dropping-new-lows
    December 18, 2024 - The hospital information technology team, aided by a multidisciplinary task force that was convened to

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74121/psn-pdf
    November 30, 2021 - deaths, but now account for about one- third.4 With medical advances and use of assisted reproductive technology

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60542/psn-pdf
    May 27, 2020 - Technology utilization to prevent medication errors. Curr Drug Saf. 2010;5(1):13-8. 16.

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49537/psn-pdf
    June 01, 2007 - receive care from doctors who belong to different health delivery systems with separate information technology

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49737/psn-pdf
    June 01, 2015 - Innovation in bladder assessment: use of technology in extended care.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49721/psn-pdf
    December 01, 2014 - Mastery learning of temporary hemodialysis catheter insertion by nephrology fellows using simulation technology
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