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  1. psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
    August 04, 2021 - SPOTLIGHT CASE The NSTEMI Curbside Consultation Citation Text: Villablanca AC, Wong GX. The NSTEMI Curbside Consultation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scho…
  2. psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
    October 27, 2022 - Ensure the patient has adequate supply of long-acting opioids by not only assessing the last fill date
  3. psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
    September 28, 2022 - Primary Care and Patient Safety: Opportunities at the Interface September 28, 2022  Also Read the Conversations In Conversation With... Freya Spielberg, MD, MPH In Conversation With... Jack Westfall, MD, MPH View more articles from the same authors. …
  4. psnet.ahrq.gov/innovation/implementing-watcher-program-improve-timeliness-recognition-deterioration-hospitalized
    June 30, 2021 - EMERGING INNOVATIONS Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Citation Text: Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Evans S, Green A, Roberson A, et al. …
  5. psnet.ahrq.gov/innovation/awareness-human-factors-operating-theatres-during-covid-19-pandemic
    January 13, 2021 - EMERGING INNOVATIONS Awareness of human factors in the operating theatres during the COVID-19 pandemic Citation Text: Britton CR, Hayman G, Stroud N. Awareness of Human Factors in the operating theatres during the COVID-19 pandemic. Journal of Perioperative Practice. 2020;31(1-2). doi:10.1177/1750…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33562/psn-pdf
    September 15, 2024 - Rapid Response Systems September 15, 2024 Rapid Response Systems. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/rapid-response-systems PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field.…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33576/psn-pdf
    December 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery December 15, 2024 Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editoria…
  8. psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
    June 16, 2021 - EMERGING INNOVATIONS eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds. Citation Text: Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support duri…
  9. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
    January 01, 2022 - Spotlight Spotlight Intraosseous Line Extravasation in a Pediatric Trauma Patient Source and Credits • This presentation is based on the April 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: David Barnes, MD and Joseph Yoon, MD o…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72516/psn-pdf
    November 25, 2020 - Premature Closure: Was It Just Syncope? November 25, 2020 Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49849/psn-pdf
    January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep January 1, 2019 Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep Case Objectives List the patient safety events that are unique to in…
  12. psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
    November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. Citation Text: Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
  13. psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
    January 29, 2021 - Misconnection Leading to Arterial Thrombosis Citation Text: Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bib…
  14. psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
    April 27, 2022 - Annual Perspective Annual Perspective: Topics in Medication Safety March 31, 2022  View more articles from the same authors. Citation Text: Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet]. Rockville (MD): Ag…
  15. psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
    February 26, 2025 - In Conversation With… J. Bryan Sexton, PhD, MA August 1, 2013  Citation Text: In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citati…
  16. psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
    August 02, 2015 - SPOTLIGHT CASE Despite Clues, Failed to Rescue Citation Text: Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…
  17. 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. Copy Citation Format: …
  18. psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
    July 01, 2011 - SPOTLIGHT CASE Spotlight: Mistaken Attribution, Diagnostic Misstep Citation Text: Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citat…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73153/psn-pdf
    April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough April 28, 2021 Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough Disclosure of Relev…
  20. psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
    July 01, 2006 - and just culture, which includes the disclosure of harm to patients and the human-resource aspects of assessing

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