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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
    January 01, 2021 - Spotlight Spotlight The Consequences of Miscommunication Regarding a Possible Artifact Source and Credits • This presentation is based on the June 2021 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Kriti Gwal, MD o AHRQ WebM&M Edit…

  2. Listen to the Family | PSNet

    psnet.ahrq.gov/web-mm/listen-family
    April 15, 2015 - Listen to the Family Citation Text: Campbell D. Listen to the Family. 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 Endnote tagged PubMedId…

  3. Looking for Meds in All the Wrong Places | PSNet

    psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
    June 16, 2021 - Looking for Meds in All the Wrong Places Citation Text: Manias E. Looking for Meds in All the Wrong Places. 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…

  4. Chemotherapy Administration Safety Standards | PSNet

    psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
    March 30, 2016 - Chemotherapy Administration Safety Standards Citation Text: Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX En…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49751/psn-pdf
    January 01, 2016 - New Patient Mistakenly Checked in as Another January 1, 2016 Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another The Case A 55-year-old man, presented to a primary care physician's office for an initial vis…

  6. Toxic Tachycardia | PSNet

    psnet.ahrq.gov/web-mm/toxic-tachycardia
    March 01, 2005 - Toxic Tachycardia Citation Text: Wartofsky L. Toxic Tachycardia. 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 …

  7. Primers | PSNet

    psnet.ahrq.gov/primers-0
    March 15, 2025 - Primers Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Latest Primers Clinical Decision Support Systems March…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49808/psn-pdf
    October 01, 2017 - High-Risk Medications, High-Risk Transfers October 1, 2017 Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers The Case A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …

  9. A "Weak" Response | PSNet

    psnet.ahrq.gov/web-mm/weak-response
    February 24, 2011 - A "Weak" Response Citation Text: Reisman AB. A "Weak" Response. 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 Endnote tagged PubMedId RIS …

  10. Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training | PSNet

    psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
    February 28, 2024 - Some of the top priorities we identified included the transition to virtual teams and how changes in

  11. Cultural Dimensions of Depression | PSNet

    psnet.ahrq.gov/web-mm/cultural-dimensions-depression
    September 01, 2018 - Cultural Dimensions of Depression Citation Text: Kinzie DJ. Cultural Dimensions of Depression. 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 XM…

  12. ACGME's 2017 Revision of Common Program Requirements | PSNet

    psnet.ahrq.gov/perspective/acgmes-2017-revision-common-program-requirements
    January 31, 2018 - ACGME's 2017 Revision of Common Program Requirements Kathy Malloy; Timothy P. Brigham, PhD; Thomas J. Nasca, MD | August 1, 2017  View more articles from the same authors. Citation Text: Malloy K, Brigham TP, Nasca TJ. ACGME's 2017 Revision of Common Program Requir…

  13. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
    January 01, 2022 - Spotlight Spotlight Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis Source and Credits • This presentation is based on the November 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Narath Carlile MD MPH,…

  14. Diuretics and Electrolyte Abnormalities | PSNet

    psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
    February 15, 2017 - Diuretics and Electrolyte Abnormalities Citation Text: Dreischulte T. Diuretics and Electrolyte Abnormalities. 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 …

  15. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
    May 01, 2015 - PowerPoint Presentation Spotlight Errors in Sepsis Management This presentation is based on the May 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF) Editor, AHRQ WebM&M: Rober…

  16. Too Many Cooks Spotlight Pdf (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
    January 01, 2020 - Spotlight Too Many Cooks in the Kitchen Source and Credits • This presentation is based on the August 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Richard P. Dutton, MD, MBA o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…

  17. Over Not So Easy | PSNet

    psnet.ahrq.gov/web-mm/over-not-so-easy
    April 01, 2005 - Over Not So Easy Citation Text: Cucina R. Over Not So Easy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  18. Procedural Mishap: Learning Curve? | PSNet

    psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
    April 28, 2021 - Procedural Mishap: Learning Curve? Citation Text: Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

  19. Building a Safety Program Using Principles of Resilience Engineering | PSNet

    psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
    October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019  View more articles from the same authors. Citation Text: Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…

  20. Delayed Clozapine Prescription in an Elderly Man With Dementia | PSNet

    psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
    August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia Citation Text: Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cita…
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