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8821. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49389/psn-pdf
      February 01, 2003 - Procedural Mishap: Learning Curve? February 1, 2003 Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve The Case A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had undesired fert…

8822. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49770/psn-pdf
      September 01, 2016 - Wrong-Time Error With High-Alert Medication September 1, 2016 Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication The Case A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…

8823. Spotlight Case (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
      May 01, 2006 - Spotlight Case Spotlight Case May 2006 Right? Left? Neither! Source and Credits This presentation is based on the May 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD…

8824. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49649/psn-pdf
      March 01, 2012 - Cultural Dimensions of Depression March 1, 2012 Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression The Case A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability to breathe and swallow…

8825. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
      January 01, 2020 - PowerPoint Presentation Spotlight A ʺReflexiveʺ Diagnosis in Primary Care 1 This presentation is based on the April 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John Betjemann, MD, and S. Andrew Josephson, MD, University of California, San…

8826. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60653/psn-pdf
      April 25, 2020 - Health Care Delivery and Pharmacists During the COVID- 19 Pandemic June 29, 2020 Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic Medication…

8827. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/836942/psn-pdf
      April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room April 27, 2022 Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-m…

8828. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33876/psn-pdf
      August 01, 2018 - Building a Safety Program in a Vast Health Care Network March 1, 2019 Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network Perspective Background As hospital-based health care in the United …

8829. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49456/psn-pdf
      July 12, 2004 - Glucose Roller Coaster July 1, 2004 Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/glucose-roller-coaster The Case A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was significant for dialysis-dependent, end-stage kidney d…

8830. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49805/psn-pdf
      September 01, 2017 - The Forgotten Radiographic Read September 1, 2017 Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read The Case A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for management of inferior…

8831. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
      February 01, 2006 - Spotlight Case [MONTH] 2003 Spotlight Case February 2006 Lost in Transition Source and Credits This presentation is based on the February 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Christopher Beach, MD; Northwe…

8832. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/72624/psn-pdf
      January 05, 2021 - The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm January 5, 2021 https://psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework- reducing-inpatient-harm Summary Building on the company’s experience as a Hospital Engagement Network…

8833. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
      March 01, 2011 - Spotlight Case July 2008 Spotlight Case March 2011 Volume Too Low: In and Out Pediatric Patient Safety * * Source and Credits This presentation is based on the March 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Marlene Miller, MD, MSc…

8834. Radiation Safety | PSNet
      psnet.ahrq.gov/primer/radiation-safety
      September 15, 2024 - Radiation Safety Citation Text: Radiation 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 XML Endnote tagged PubMedId RIS Downl…

8835. Ruptured Heterotopic Pregnancy | PSNet
      psnet.ahrq.gov/web-mm/ruptured-heterotopic-pregnancy
      August 16, 2023 - Ruptured Heterotopic Pregnancy Citation Text: Cedars MI. Ruptured Heterotopic Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

8836. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-11/spotlight_case_neurological_red_flags_final.pptx
      January 01, 2024 - Spotlight Spotlight Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache 1 Source and Credits This presentation is based on the November 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Jonatha…

8837. Errors and Near Misses: What Health Care Could Learn From Aviation | PSNet
      psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
      September 01, 2006 - Errors and Near Misses: What Health Care Could Learn From Aviation Carl Macrae, PhD | December 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation…

8838. The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance | PSNet
      psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
      April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance Lance L. Roberts, MS; Marcia M. Ward, PhD; Thomas C. Evans, MD | April 1, 2010  Also Read a Conversation View more articles from the same authors. …

8839. Diagnostic Errors | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors
      December 01, 2013 - Perspectives on Safety Annual Perspective Technology as a Tool

8840. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/850673/psn-pdf
      June 14, 2023 - A practical, insightful recommendation from advisors—a succinct, clear, practical tool that tells a