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  1. psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
    January 31, 2024 - Annual Perspective Improving Diagnostic Safety and Quality Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD | April 26, 2023  View more articles from the same authors. Citation Text: Al-Khafaji J, Lee M, Mossburg S. Improving Di…
  2. psnet.ahrq.gov/web-mm/nothing-called-small-surgery
    February 01, 2023 - Nothing Called Small Surgery Citation Text: Manske C. Nothing Called Small Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851099/psn-pdf
    June 28, 2023 - Misconnection Leading to Arterial Thrombosis June 28, 2023 Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis The Case A 55-year-old man with chronic obstructive pulmonary disease (COPD) was brought by am…
  4. 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…
  5. 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. …
  6. psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx Spotlight Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849679/psn-pdf
    June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture June 28, 2023 Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848107/psn-pdf
    April 26, 2023 - Improving Diagnostic Safety and Quality April 26, 2023 Al-Khafaji J, Lee M, Mossburg S. Improving Diagnostic Safety and Quality . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality Introduction During an annual editorial review of featured articles in the Agency for …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74120/psn-pdf
    November 30, 2021 - Patients with lower health literacy were more likely to choose “aggressive treatments” at the end of
  10. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
    January 01, 2021 - – Patients with lower health literacy were more likely to choose “aggressive treatments” at the end
  11. psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
    August 01, 2006 - SPOTLIGHT CASE Right Regimen, Wrong Cancer: Patient Catches Medical Error Citation Text: Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
  12. psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
    September 01, 2016 - SPOTLIGHT CASE Multifactorial Medication Mishap Citation Text: Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNot…
  13. psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
    December 04, 2016 - SPOTLIGHT CASE Palliative Care: Comfort vs. Harm Citation Text: Jox RJ. Palliative Care: Comfort vs. Harm. 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…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33867/psn-pdf
    October 01, 2018 - In Conversation With… Michael Cohen, RPh, MS, ScD (hon) October 1, 2018 In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0 Editor's note: Dr. Cohen is President of the Institute for Safe Medication Practice…
  15. psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
    May 01, 2018 - SPOTLIGHT CASE Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency Citation Text: Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  16. psnet.ahrq.gov/web-mm/isolated-clot-real-error
    December 01, 2013 - SPOTLIGHT CASE Isolated Clot, Real Error Citation Text: Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  17. psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
    April 01, 2010 - performance, exacerbating the transparency problem, as in many instances these stakeholders may "pick and choose
  18. psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
    November 01, 2017 - be more responsible for their care by providing them with the ability to access health information, choose
  19. psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
    April 01, 2010 - performance, exacerbating the transparency problem, as in many instances these stakeholders may "pick and choose
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60362/psn-pdf
    April 13, 2018 - Many of the reasons that programs may choose to not join have been uncovered so that they can be addressed

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