-
psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - WebM&M Cases
Agitated Delirium Contributes to Missed Testing
-
psnet.ahrq.gov/web-mm/forgotten-turn
August 01, 2018 - End Despite End-of-Life Care Planning
August 1, 2018
A simulation systems testing
-
psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - technology-focused solutions developed in research environments will require appropriate real-world testing
-
psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
December 08, 2021 - symptoms concerning for unstable angina and determined that the patient would require additional cardiac testing
-
psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - open-ended questions may help team members to obtain important information on affordability and access to testing
-
psnet.ahrq.gov/node/49499/psn-pdf
December 02, 2020 - An Outpatient 'Zebra'
January 1, 2006
Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/outpatient-zebra
The Case
A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness.
His past medical history included lumbar disc diseas…
-
psnet.ahrq.gov/node/72616/psn-pdf
December 22, 2020 - Adverse Events in Dentistry
December 22, 2020
Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/adverse-events-dentistry
Introduction
Similar to many other healthcare settings, dentistry carries with it inherent patient safety risks. D…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.221_slideshow.ppt
July 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Weighing in on Surgical Safety
*
*
Source and Credits
This presentation is based on the July 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jay B. Brodsky, MD, Stanford University Medical Cente…
-
psnet.ahrq.gov/cme
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations A man with a history of prior umbilical hernia repair presented to the emergency department (ED) with abdominal pain and was initially diagnosed with cholelithiasis before being discharged home. However, the next day he returned to …
-
psnet.ahrq.gov/node/33586/psn-pdf
December 15, 2024 - Alert Fatigue
December 15, 2024
Alert Fatigue. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/alert-fatigue
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Bac…
-
psnet.ahrq.gov/primer/pharmacists-role-medication-safety
March 14, 2018 - Pharmacist's Role in Medication Safety
Citation Text:
The Pharmacist's Role in Medication Safety. 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 XML EndNote 7…
-
psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - Unwritten rules for safety and performance in an oncology day care unit: Testing the resilience markers
-
psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - Office-Based Patient Safety
January 31, 2024
Developing perioperative Covid-19 testing
-
psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - for communicating key information about the patient's condition and instructions regarding equipment, testing
-
psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - Bed rest, hospitalization, and the testing and treatment patients receive come with a number of risks
-
psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - Bed rest, hospitalization, and the testing and treatment patients receive come with a number of risks
-
psnet.ahrq.gov/node/865884/psn-pdf
May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening
Complications after Gastric Bypass Surgery.
May 29, 2024
Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…
-
psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - SPOTLIGHT CASE
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
Citation Text:
Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
-
psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After
Emergency Cesarean Delivery.
November 30, 2021
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean
Delivery. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…
-
psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - Time of Death?
Citation Text:
Taekman JM, Wright MC. Time of Death?. 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 …