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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73906/psn-pdf
    October 06, 2021 - In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD October 6, 2021 In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd Editor’s Note: Alison Stuebe, MD, MSc, is a…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836879/psn-pdf
    April 27, 2022 - In Conversation With... Michael L. Millenson April 27, 2022 In Conversation With.. Michael L. Millenson. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-michael-l-millenson December 16, 2021 Editor’s note: Michael L. Millenson is the President of Health Quality Advisors LLC, author of the c…

  3. Pitfalls in Diagnosing Necrotizing Fasciitis | PSNet

    psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
    March 24, 2021 - SPOTLIGHT CASE Pitfalls in Diagnosing Necrotizing Fasciitis Citation Text: Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …

  4. In Conversation With… J. Bryan Sexton, PhD, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
    February 26, 2025 - In Conversation With… J. Bryan Sexton, PhD, MA August 1, 2013  Citation Text: In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citati…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867497/psn-pdf
    February 26, 2025 - Retained Surgical Items: Causation and Prevention February 26, 2025 Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention Background A retained surgical item (RSI) is a surgical patient safety pro…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33726/psn-pdf
    March 01, 2012 - In Conversation With… Richard C. Boothman, JD March 1, 2012 In Conversation With… Richard C. Boothman, JD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd Editor's note: Rick Boothman, an attorney, is the chief risk officer for the University of Michigan Health System…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49483/psn-pdf
    June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…

  8. Spotlight

    psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…

  9. Getting to the Root of the Matter | PSNet

    psnet.ahrq.gov/web-mm/getting-root-matter
    September 01, 2005 - SPOTLIGHT CASE Getting to the Root of the Matter Citation Text: Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Schola…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72911/psn-pdf
    March 15, 2021 - The Impact of Communication on Medication Errors March 15, 2021 Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors The Case   A 93-year-old man with a history of chronic systolic heart failure…

  11. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. | PSNet

    psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
    August 14, 2024 - SPOTLIGHT CASE Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. Citation Text: Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…

  12. In Conversation With... Heidi Wald, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-heidi-wald-md
    November 26, 2019 - In Conversation With... Heidi Wald, MD November 26, 2019  Also Read the Essay Citation Text: In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.In Conversation With... Heidi Wald, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …

  13. In Conversation With… Jane Brice, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
    May 01, 2019 - In Conversation With… Jane Brice, MD, MPH May 1, 2019  Also Read an Essay Citation Text: In Conversation With… Jane Brice, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Co…

  14. Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

    psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
    September 24, 2024 - Sarah Mossburg:  You’ve probably heard the concern that zero harm can be unattainable or unrealistic.

  15. Adolescent Diabetes: A Routine Visit? | PSNet

    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…

  16. Health Care Data Science for Quality Improvement and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
    October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety Alvin Rajkomar, MD | October 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Rajkomar A. Health Care Data Science for Quality Improvement and Patient S…

  17. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. | PSNet

    psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
    July 08, 2022 - SPOTLIGHT CASE A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. Citation Text: Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …

  18. Diagnosing HIV-It Doesn't Take a Brain Surgeon | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
    January 01, 2018 - SPOTLIGHT CASE Diagnosing HIV-It Doesn't Take a Brain Surgeon Citation Text: Chou R. Diagnosing HIV-It Doesn't Take a Brain Surgeon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: …

  19. In Conversation with…Peter J. Pronovost, MD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
    June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD June 1, 2005  Also Read an Essay Citation Text: In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…

  20. Spotlight Case Hindsight Is 2020 Slides Final Revised 05.03.2024 (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
    January 01, 2024 - Spotlight Hindsight is 20/20: Thrombolytics for Alcohol Intoxication Source and Credits • This presentation is based on the April 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Eric Signoff, MD, Noelle Boctor, MD, and David K. B…
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