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  1. Unexpected Drawbacks of Electronic Order Sets | PSNet

    psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets
    December 01, 2017 - Unexpected Drawbacks of Electronic Order Sets Citation Text: McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX …

  2. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
    June 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfer Troubles 1 2 Source and Credits This presentation is based on the June 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…

  3. On the Other Hand | PSNet

    psnet.ahrq.gov/web-mm/other-hand
    December 12, 2012 - On the Other Hand Citation Text: Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  4. Discharge Against Medical Advice | PSNet

    psnet.ahrq.gov/web-mm/discharge-against-medical-advice
    July 01, 2017 - Discharge Against Medical Advice Citation Text: Hwang SW. Discharge Against Medical Advice. 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 E…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33672/psn-pdf
    September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH September 1, 2008 In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph Editor's note: Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women's Hospital and Assi…

  6. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-471
    December 31, 2024 - January 22, 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, report…

  7. The Case for Patient Flow Management | PSNet

    psnet.ahrq.gov/web-mm/case-patient-flow-management
    February 23, 2019 - The Case for Patient Flow Management Citation Text: Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X…

  8. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules | PSNet

    psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
    March 25, 2020 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules Citation Text: Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33703/psn-pdf
    November 01, 2010 - Are We Getting Better at Measuring Patient Safety? November 1, 2010 Rosen AK. Are We Getting Better at Measuring Patient Safety? PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety Perspective The past decade has witnessed unprecedented interest in patient safe…

  10. Medication Mix-Up: From Bad to Worse | PSNet

    psnet.ahrq.gov/web-mm/medication-mix-bad-worse
    March 01, 2018 - Medication Mix-Up: From Bad to Worse Citation Text: Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote …

  11. Tacit Handover, Overt Mishap | PSNet

    psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72563/psn-pdf
    December 07, 2020 - In Conversation With... Katie J. Suda, PharmD, MS December 7, 2020 In Conversation With.. Katie J. Suda, PharmD, MS . PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms Editor’s Note: Katie J. Suda, PharmD, MS is a professor at the University of Pittsburgh School of Medic…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60269/psn-pdf
    April 29, 2020 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? April 29, 2020 Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tiss…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865656/psn-pdf
    April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous Combination April 24, 2024 Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination The Case A 26-ye…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73456/psn-pdf
    June 30, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia June 30, 2021 Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubat…

  16. In Conversation With… Ann L. Hendrich, RN, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
    February 26, 2025 - In Conversation With… Ann L. Hendrich, RN, PhD December 1, 2011  Citation Text: In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Cita…

  17. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.101_slideshow.ppt
    July 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case July 2005 Impatient Inpatient Dosing Source and Credits This presentation is based on the July 2005 AHRQ WebM&M Spotlight Case in Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Richard H. White…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49455/psn-pdf
    July 01, 2004 - The Worst Headache July 1, 2004 Edlow JA. The Worst Headache. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/worst-headache The Case A 48-year-old woman with a history of migraine headaches and hypertension presented to her outpatient clinic with a 4-day history of headache. While shopping 4 days earlier, …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838855/psn-pdf
    October 27, 2022 - False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. October 27, 2022 Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
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