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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867651/psn-pdf
    February 26, 2025 - Safety I, Safety II, and the New Views of Safety February 26, 2025 Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety Background and Context Safety I and Safety II (Safety I/II) are not safety method…
  2. psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
    October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…
  3. psnet.ahrq.gov/perspective/overuse-patient-safety-problem
    September 01, 2014 - Overuse as a Patient Safety Problem Christopher Moriates, MD | September 1, 2014  Also Read a Conversation View more articles from the same authors. Citation Text: Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. Rockville (MD): Agency for Heal…
  4. psnet.ahrq.gov/web-mm/tale-two-falls
    March 27, 2024 - A Tale of Two Falls Citation Text: Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
  5. psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
    March 27, 2024 - SPOTLIGHT CASE Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head Citation Text: Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
  6. psnet.ahrq.gov/web-mm/impact-communication-medication-errors
    August 01, 2009 - The Impact of Communication on Medication Errors Citation Text: Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: …
  7. psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
    October 02, 2024 - Safety I, Safety II, and the New Views of Safety Citation Text: Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX E…
  8. psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
    January 04, 2024 - Retained Surgical Items: Causation and Prevention Citation Text: Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX End…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867035/psn-pdf
    October 30, 2024 - A Tale of Two Falls October 30, 2024 Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/tale-two-falls The Cases Case #1: A 79-year-old woman with a history of impaired cognition at baseline was brought from a skilled nursing facility to the emergency department (ED) f…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866370/psn-pdf
    July 31, 2024 - Intraoperative Awareness during Rhinoplasty July 31, 2024 Bohringer C, Toor J. Intraoperative Awareness during Rhinoplasty. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation …
  11. psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
    November 18, 2016 - SPOTLIGHT CASE Adolescent Diabetes: A Routine Visit? Citation Text: Slap GB. Adolescent Diabetes: A Routine Visit?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar Bi…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74149/psn-pdf
    January 07, 2022 - Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings January 7, 2022 Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/multiple-missed-opportu…
  13. 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…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853774/psn-pdf
    September 27, 2023 - Delayed Evaluation of Abdominal Pain in an Elderly Patient. September 27, 2023 Klimkiv L, Utter GH, Barnes DK. Delayed Evaluation of Abdominal Pain in an Elderly Patient. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient The Case An 85-year-old woman presente…
  15. psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
    October 31, 2023 - SPOTLIGHT CASE Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. Citation Text: Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60611/psn-pdf
    June 24, 2020 - Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing June 24, 2020 Giannini J, Wong M, Dager W, et al. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk…
  17. psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
    September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? Ashish K. Jha, MD, MPH | September 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Jha AK. What Can the Rest of the Heal…
  18. psnet.ahrq.gov/perspective/safety-medical-devices
    June 01, 2011 - The Safety of Medical Devices Christopher Nemeth, PhD | June 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865655/psn-pdf
    April 24, 2024 - Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. April 24, 2024 Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-comp…
  20. Psn-Pdf (pdf file)

    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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