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psnet.ahrq.gov/node/867653/psn-pdf
February 26, 2025 - In Conversation with Jessica Behrhorst about The
Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. In Conversation with Jessica Behrhorst about The Evolution of Root Cause
Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evoluti…
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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - In Conversation with Timothy Vogus about High
Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization
(HRO) Principles and Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/persp…
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/node/857061/psn-pdf
November 27, 2023 - In Conversation with... Joan Stanley about The Role of
Undergraduate Nursing Education in Patient Safety
November 27, 2023
Stanley J. In Conversation with.. Joan Stanley about The Role of Undergraduate Nursing Education in
Patient Safety . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-joa…
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psnet.ahrq.gov/node/838222/psn-pdf
September 28, 2022 - In Conversation With... Jack Westfall, MD, MPH
September 28, 2022
In Conversation With.. Jack Westfall, MD, MPH. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
Editor’s note: Jack Westfall, MD, MPH, is a retired professor from the University of Colorado School of
Medic…
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - Complications of ECMO During Transport
April 29, 2020
Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
The Case
A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with
acute on chro…
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - SPOTLIGHT CASE
A Fatal Twist in Pseudohyperkalemia
Citation Text:
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
November 02, 2016 - Promising Areas for Patient Safety Research
P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH | December 1, 2003
View more articles from the same authors.
Citation Text:
Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. …
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psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD
August 1, 2016
Also Read an Essay
Citation Text:
In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Heal…
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psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
February 26, 2025 - In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD
April 1, 2019
Citation Text:
In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety
Jane Ball, PhD, and Peter Griffiths, PhD | March 1, 2018
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient…
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/perspective/overuse-patient-safety-problem
September 01, 2014 - Overuse as a Patient Safety Problem
Christopher Moriates, MD | September 1, 2014
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. Rockville (MD): Agency for Heal…
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psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
September 01, 2014 - In Conversation With… Rosemary Gibson, MSc
September 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - When the Meds Don’t Reach the Bed
August 26, 2020
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
The Case
A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of
chronic obs…
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psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
March 30, 2020 - Making Healthcare Safer III Report
March 30, 2020
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. Rockville (MD): Agency for Health…
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - In Conversation With… Mark L. Graber, MD
January 1, 2016
In Conversation With… Mark L. Graber, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
Editor's note: Dr. Graber is a Senior Fellow at RTI International and Professor Emeritus of Medicine at
the State University o…
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - Complications of ECMO During Transport
Citation Text:
Broman M. Complications of ECMO During Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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