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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - SPOTLIGHT CASE
Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough
Citation Text:
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - Interpreting the Patient Safety Literature
Kaveh G. Shojania, MD | June 1, 2005
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View more articles from the same authors.
Citation Text:
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only
Spotlight
Delay in Appropriate Diagnosis and
Treatment Leading to Death from
Pulmonary Embolism
Source and Credits
• This presentation is based on the February 2021 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/node/850673/psn-pdf
June 14, 2023 - In Conversation with... Beverley H. Johnson about The
Role of Patient's Family In Reducing Harm
June 14, 2023
Johnson B. In Conversation with.. Beverley H. Johnson about The Role of Patient's Family In Reducing
Harm. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-r…
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - AHRQ PSNet Webinar
AHRQ PSNet Webinar
Making Healthcare Safer (MHS) IV:
Rapid Response Systems and Opioid Stewardship
February 10, 2025
Agenda
2
• Logistics
• Introduction to the Making Healthcare Safer (MHS) IV Reports
• Report 1 – Rapid Response Systems
► Discussion
► PSNet Resources
• Report 2 – Opioi…
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc
October 30, 2019
Citation Text:
In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation…
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - SPOTLIGHT CASE
A Missed Bowel Perforation - the Importance of Diagnostic Reasoning
Citation Text:
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
October 01, 2007 - Making Just Culture a Reality: One Organization's Approach
Alison H. Page, MS, MHA | October 1, 2007
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Citation Text:
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [in…
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE)
Collaborative Studies and Implements Methods to Prevent
Avoidable Cases of Hospital Associated VTE
April 7, 2022
https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-
implements-methods
Summary
Venous thromboembolism (…
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - SPOTLIGHT CASE
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression
Citation Text:
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - Culture Clash No More: Integration and Coordination of
Disease Treatment and Palliative Care
November 30, 2021
Spero H, Usher AE, Howard B, et al. Culture Clash No More: Integration and Coordination of Disease
Treatment and Palliative Care . PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/culture-clash-no-mo…
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - SPOTLIGHT CASE
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
Citation Text:
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD
October 1, 2010
Also Read an Essay
Citation Text:
In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010.In Conversation with...Peter J. Pronovost, MD, PhD. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/perspective/what-makes-good-checklist
October 01, 2010 - What Makes a Good Checklist
Anne Collins McLaughlin, PhD | October 1, 2010
Also Read a Conversation
View more articles from the same authors.
Citation Text:
McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - SPOTLIGHT CASE
Premature Closure: Was It Just Syncope?
Citation Text:
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citation
Format:
…
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
October 24, 2021 - In Conversation With… Michael Cohen, RPh, MS, ScD (hon)
October 1, 2018
Citation Text:
In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - In Conversation with…Robert M. Wachter, MD
October 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Robert M. Wachter, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008…
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psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
January 01, 2021 - Spotlight
Spotlight
Culture Clash No More:
Integration and Coordination of Disease
Treatment and Palliative Care
Source and Credits
• This presentation is based on the November 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: Han…
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries
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July 8, 2022
Innovation
Contact
…
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psnet.ahrq.gov/web-mm/culture-clash-no-more-integration-and-coordination-disease-treatment-and-palliative-care
December 23, 2020 - SPOTLIGHT CASE
Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care
Citation Text:
Spero H, Usher AE, Howard B, et al. Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care . PSNet [internet]. Rockville (MD): Agency f…