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  1. psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
    January 03, 2017 - SPOTLIGHT CASE Treatment Challenges After Discharge Citation Text: Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar Bib…
  2. psnet.ahrq.gov/web-mm/missed-appendicitis
    March 13, 2013 - SPOTLIGHT CASE Missed Appendicitis Citation Text: Adams JG. Missed Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
  3. psnet.ahrq.gov/web-mm/failure-latch
    November 27, 2012 - Failure to Latch Citation Text: Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33877/psn-pdf
    April 01, 2019 - In Conversation With… Timothy B. McDonald, MD, JD April 1, 2019 In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd Editor's note: Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865656/psn-pdf
    April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous Combination April 24, 2024 Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination The Case A 26-ye…
  6. psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. 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 XML E…
  7. psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Jaenic Lee, MD Josh Fernel…
  8. psnet.ahrq.gov/web-mm/techno-trip
    May 01, 2005 - Techno Trip Citation Text: Cook RI. Techno Trip. 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 Downlo…
  9. psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
    January 01, 2016 - MG : The progress in accepting diagnostic error as a major safety concern has been very slow.
  10. psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety Joan Stanley, PhD, NP, FAAN, FAANP | November 27, 2023  Also Read the Essay View more articles from the same authors. Citation Text: Stanley J. In Conversat…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60721/psn-pdf
    July 21, 2020 - Special Edition Perspective: Technology Responses to COVID-19 July 21, 2020 Marcin JP, Cohen NM, Lowery C, et al. Special Edition Perspective: Technology Responses to COVID-19. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19 Editor’s note: This …
  12. psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
    February 26, 2025 - some of the issues for not getting credit for the bundle were mechanical, while others were out of concern
  13. psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
    February 26, 2025 - some of the issues for not getting credit for the bundle were mechanical, while others were out of concern
  14. psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
    June 01, 2018 - There will always be concern of errors of overdiagnosing and misdiagnosing conditions with ultrasound
  15. psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
    December 18, 2024 - challenge. 5 ECRI identified ongoing challenges with preventing patient falls as a top ten patient safety concern
  16. psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - The Role of Undergraduate Nursing Education in Patient Safety Joan Stanley, PhD, NP, FAAN, FAANP; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD | November 27, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Stanley J, Ga…
  17. psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
    December 18, 2024 - challenge. 5 ECRI identified ongoing challenges with preventing patient falls as a top ten patient safety concern
  18. psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
    December 01, 2010 - in its seminal report, To Err Is Human ( 2 ), that the issue of medical mistakes became a national concern
  19. psnet.ahrq.gov/perspective/workplace-safety-health-care
    January 01, 2017 - How do you address that concern?
  20. psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
    January 01, 2017 - How do you address that concern?

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