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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - scores, looking at lawsuit settlements and payments, and trying to determine where the hospital stood compared
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - Another example is Toyota compared with its competitors.
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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.
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psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - SPOTLIGHT CASE
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
Citation Text:
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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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/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-…
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psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - SPOTLIGHT CASE
Delay in Treatment: Failure to Contact Patient Leads to Significant Complications
Citation Text:
Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…
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psnet.ahrq.gov/node/33833/psn-pdf
May 01, 2017 - In Conversation With… David Juurlink, MD, PhD
May 1, 2017
In Conversation With… David Juurlink, MD, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
Editor's note: Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of
Toronto, w…
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psnet.ahrq.gov/node/49721/psn-pdf
December 01, 2014 - Ebola: Are We Ready?
December 1, 2014
Barsuk JH, Barnard C. Ebola: Are We Ready? PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/ebola-are-we-ready
The Case
A 28-year-old man, well-appearing but pale, walked into the emergency department (ED) on a Wednesday
afternoon at 3 PM complaining of nausea, vomiting,…
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psnet.ahrq.gov/node/61083/psn-pdf
October 28, 2020 - In Conversation With... Charles A Crecelius, MD, PhD,
CMD and Lori L Popejoy, PhD, RN, FAAN
October 28, 2020
In Conversation With.. Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-po…
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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…
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
Editor's note: Dr. Chassin is president and chief executive officer of The Joint Commission. He is also
p…
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
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August 30, 2023
View more articles from the…
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/49813/psn-pdf
January 01, 2018 - Dying in the Hospital With Advanced Dementia
December 1, 2017
Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
Case Objectives
Recognize the importance of eliciting patient preferences and go…
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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…
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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…
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psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
December 08, 2021 - SPOTLIGHT CASE
When Patients and Providers Speak Different Languages
Citation Text:
Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
May 19, 2021 - SPOTLIGHT CASE
Postdischarge Follow-Up Phone Call
Citation Text:
Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. 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/web-mm/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis.
Citation Text:
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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