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  1. In Conversation With… Robert Hirschtick, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
    January 01, 2018 - In Conversation With… Robert Hirschtick, MD January 1, 2018  Also Read an Essay Citation Text: In Conversation With… Robert Hirschtick, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

  2. 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 - 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…

  3. In Conversation With… David M. Gaba, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
    March 01, 2013 - In Conversation With… David M. Gaba, MD March 1, 2013  Also Read an Essay Citation Text: In Conversation With… David M. Gaba, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy…

  4. Moving Pains | PSNet

    psnet.ahrq.gov/web-mm/moving-pains
    August 17, 2017 - SPOTLIGHT CASE Moving Pains Citation Text: Schell H, Wachter R. Moving Pains. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  5. No News May Not Be Good News | PSNet

    psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
    December 07, 2009 - SPOTLIGHT CASE No News May Not Be Good News Citation Text: Moore CR. No News May Not Be Good News. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  6. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest | PSNet

    psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
    April 01, 2008 - In this case, review of the numerous failed attempts at cannulation should have raised concern about

  7. The Empty Bag | PSNet

    psnet.ahrq.gov/web-mm/empty-bag
    June 01, 2018 - The Empty Bag Citation Text: Vincent C. The Empty Bag. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  8. Mismanagement of Delirium | PSNet

    psnet.ahrq.gov/web-mm/mismanagement-delirium
    February 13, 2014 - The intern further explained that the primary medical concern was the patient's behavior, not his mobility

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33732/psn-pdf
    July 01, 2012 - RW: People have raised the concern of the "glass cockpit syndrome," where if we go too far in the direction

  10. In Conversation With… Rebecca Lawton, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-rebecca-lawton-phd
    March 24, 2025 - In Conversation With… Rebecca Lawton, PhD September 1, 2018  Citation Text: In Conversation With… Rebecca Lawton, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …

  11. Organizational Learning | PSNet

    psnet.ahrq.gov/curated-library/organizational-learning
    September 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Organizational Learning  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49579/psn-pdf
    March 21, 2009 - All in the History March 21, 2009 Fee C. All in the History. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/all-history Case Objectives Describe the Emergency Medical Treatment and Active Labor Act (EMTALA) and understand that it does not apply to transfers to emergency departments from non-acute care faci…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842919/psn-pdf
    February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis. February 1, 2023 Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis The Cases Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49852/psn-pdf
    February 01, 2019 - Triaging Interhospital Transfers February 1, 2019 Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/triaging-interhospital-transfers Case Objectives Recognize that transfer of patients between acute care hospitals is common. Realize that the interhospital transfer…

  15. Blind Spot | PSNet

    psnet.ahrq.gov/web-mm/blind-spot
    July 30, 2020 - Blind Spot Citation Text: Lee LA. Blind Spot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837791/psn-pdf
    August 05, 2022 - Patient Safety in the Ambulatory Care Setting August 5, 2022 Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting Introduction There is no way to review the year 2021 in quality and …

  17. In Conversation With… Thomas J. Nasca, MD, MACP | PSNet

    psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
    July 10, 2024 - The third dimension is our ongoing attention and real concern about professionalism and professional

  18. A Weighty Mistake | PSNet

    psnet.ahrq.gov/web-mm/weighty-mistake
    September 01, 2016 - SPOTLIGHT CASE A Weighty Mistake Citation Text: Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49825/psn-pdf
    April 01, 2018 - When Patients and Providers Speak Different Languages April 1, 2018 Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages Case Objectives Understand the legal and regulatory obligations to prov…

  20. In Conversation with...Patrick S. Romano, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
    July 10, 2024 - Many diagnoses that might represent adverse events were discarded through this process, because of concern
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