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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - to learn all entry methods, so that in case of difficult entry, a backup method can be employed. 8
Approaches
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psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
January 01, 2008 - Implementing a Patient Safety Program at a Large National Health System
Loran Hauck, MD, and Jan Jacob, MBA, RN | January 1, 2008
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Hauck LD, Jacob J. Implementing a Patient Safety …
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psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
November 01, 2012 - The Evidence-Based Physical Examination as a Patient Safety Practice
Steven McGee, MD | November 1, 2012
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Citation Text:
McGee S. The Evidence-Based Physical Examination as a Patient Safety Pract…
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - But I would say overall there is consistent evidence that these high reliability approaches are
associated
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psnet.ahrq.gov/web-mm/compare-and-contrast
July 16, 2019 - SPOTLIGHT CASE
Compare and Contrast
Citation Text:
Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/pregnant-danger
January 12, 2011 - Pregnant With Danger
Citation Text:
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
March 01, 2004 - SPOTLIGHT CASE
The Lung Nodule That Refused To Grow
Citation Text:
Balekian AA, Gould MK. The Lung Nodule That Refused To Grow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/851870/psn-pdf
July 31, 2023 - In Conversation with... Regina Hoffman about Building
Capacity for Patient Safety
July 31, 2023
In Conversation with.. Regina Hoffman about Building Capacity for Patient Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
Editor’s no…
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Transitions in Adolescent Medicine
Citation Text:
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
February 26, 2025 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
Citation Text:
In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - Getting a Good Report Card: Unintended Consequences
of the Public Reporting of Hospital Quality
November 1, 2006
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of
Hospital Quality. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…
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psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
April 01, 2008 - Anticoagulation: Held Too Long
Citation Text:
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument
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January …
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psnet.ahrq.gov/node/33740/psn-pdf
November 01, 2012 - In Conversation With… Abraham Verghese, MD
November 1, 2012
In Conversation With… Abraham Verghese, MD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-abraham-verghese-md
Editor's note: Abraham Verghese, MD, is Professor for the Theory and Practice of Medicine at the
Stanford University S…
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - Which Line: Ordering Provider or Proceduralist?
March 1, 2019
Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse…
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psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - Mobility Lost in the ICU
October 1, 2011
Smith J. Mobility Lost in the ICU. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/mobility-lost-icu
Case Objectives
Describe the role of the physical therapist in the hospital and ICU.
Compare the risks from immobility with the benefits gained from a program of ther…
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - SPOTLIGHT CASE
Prolonged DKA in Pregnancy: A Case of Communication Breakdown.
Citation Text:
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - Missed CANDOR Implementation Opportunities.
Citation Text:
Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
May 31, 2023 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
Citation Text:
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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