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  1. psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
    June 01, 2003 - SPOTLIGHT CASE Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care Citation Text: Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
  2. psnet.ahrq.gov/web-mm/privacy-or-safety
    December 01, 2011 - SPOTLIGHT CASE Privacy or Safety? Citation Text: Halamka JD, McGraw D. Privacy or Safety?. 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 X3 XML EndNo…
  3. psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
    March 24, 2019 - Hypoxemia after Emergency Intubation Citation Text: Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…
  4. psnet.ahrq.gov/web-mm/another-fall
    June 01, 2010 - SPOTLIGHT CASE Another Fall Citation Text: Bogardus SG. Another Fall. 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 EndNote 7 XML Endnote tagg…
  5. psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
    February 26, 2025 - In Conversation With… Eric J. Topol, MD September 1, 2015  Citation Text: In Conversation With… Eric J. Topol, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Form…
  6. psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
    September 01, 2004 - SPOTLIGHT CASE Unintended Consequences of CPOE Citation Text: Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNot…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867357/psn-pdf
    December 18, 2024 - Hypoxemia after Emergency Intubation December 18, 2024 Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation The Case A 19-month-old child was brought to the emergency department (ED) via ambulance after drowning in a p…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866618/psn-pdf
    December 31, 2024 - A Fatal Twist in Pseudohyperkalemia December 31, 2024 Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for C…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49792/psn-pdf
    May 01, 2017 - Diagnostic Delay in the Emergency Department May 1, 2017 Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department Case Objectives Appreciate the importance of a broad differential diagnosis for acute abdominal pai…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near- Miss Wrong Transfusion Event January 29, 2020 Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
  11. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33787/psn-pdf
    January 01, 2018 - In Conversation With… Maureen Bisognano June 1, 2015 In Conversation With… Maureen Bisognano. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-maureen-bisognano Editor's note: Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement (IHI). We spoke with her about I…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33869/psn-pdf
    November 01, 2018 - In Conversation With… David Meltzer, MD, PhD November 1, 2018 In Conversation With… David Meltzer, MD, PhD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd Editor's note: Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medici…
  14. psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
    July 23, 2024 - Suicide Prevention in an Emergency Department Population: ED-SAFE Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL April 24, 2024 View more articles from the same authors. Innovation …
  15. Psn-Pdf (pdf file)

    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…
  16. psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - By setting clear criteria for which events to analyze in-depth, RCA 2 helps healthcare organizations
  17. psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
    November 16, 2022 - as a new prescription or deprescribing of an existing prescription. 12 Other PSLLs have used HFE to analyze
  18. psnet.ahrq.gov/perspective/evolution-root-cause-analysis
    February 26, 2025 - By setting clear criteria for which events to analyze in-depth, RCA 2 helps healthcare organizations
  19. psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
    March 03, 2021 - SPOTLIGHT CASE Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. Citation Text: Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…
  20. psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
    February 26, 2025 - In Conversation With… Leah Binder, MA, MGA April 1, 2014  Citation Text: In Conversation With… Leah Binder, MA, MGA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Fo…

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