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9921. Accreditation and Regulation: Can They Help Improve Patient Safety? | PSNet
      psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
      April 01, 2009 - This is consistent with the pattern in other safe industries; outside pressure can help promote the cultural

9922. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations | PSNet
      psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
      September 27, 2023 - Cultural or linguistic barriers, or fears of legal or occupational consequences, may interfere with obtaining

9923. Spotlight
      psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
      January 01, 2024 - Failure to do so in this case suggests implicit bias, perhaps due to the patient's age cultural or communication

9924. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice | PSNet
      psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
      January 01, 2016 - It's almost a cultural taboo.

9925. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness | PSNet
      psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
      February 01, 2014 - EC : That's a very important cultural issue.

9926. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49764/psn-pdf
      June 01, 2016 - Communication With Consultants June 1, 2016 Cohn SL. Communication With Consultants. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/communication-consultants The Case A 30-year-old pregnant woman presented to the emergency department (ED) with nausea, headaches, and fevers. Her laboratory studies were nota…

9927. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
      February 01, 2011 - Spotlight Case July 2008 Spotlight Case One Toxic Drug Is Not Like Another * * Source and Credits This presentation is based on the February 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Eric S. Holmboe, MD, American Board of Internal…

9928. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
      May 01, 2011 - Spotlight Case July 2008 Spotlight Case Duty to Disclose Someone Else’s Error * * Source and Credits This presentation is based on the May 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Thomas H. Gallagher, MD University of Washington …

9929. CE/MOC Quizzes | PSNet
      psnet.ahrq.gov/cme
      February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations A man with a history of prior umbilical hernia repair presented to the emergency department (ED) with abdominal pain and was initially diagnosed with cholelithiasis before being discharged home. However, the next day he returned to …

9930. Nothing Called Small Surgery | PSNet
      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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

9931. Multifactorial Medication Mishap | PSNet
      psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
      September 01, 2016 - SPOTLIGHT CASE Multifactorial Medication Mishap Citation Text: Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNot…

9932. In Conversation With… Paul Aylin, MBChB | PSNet
      psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
      June 01, 2017 - In Conversation With… Paul Aylin, MBChB June 1, 2017  Also Read an Essay Citation Text: In Conversation With… Paul Aylin, MBChB. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy …

9933. Delayed Diagnosis of Endocrinologic Emergencies | PSNet
      psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
      November 13, 2024 - Delayed Diagnosis of Endocrinologic Emergencies Citation Text: Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google …

9934. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33878/psn-pdf
      April 01, 2019 - In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD April 1, 2019 In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd Editor's note: Dr. Schulz Moore is the Director of Learning and Teaching at…

9935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33787/psn-pdf
      January 01, 2018 - In Conversation With… Maureen Bisognano June 1, 2015 In Conversation With… Maureen Bisognano. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-maureen-bisognano Editor's note: Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement (IHI). We spoke with her about I…

9936. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49737/psn-pdf
      June 01, 2015 - Unseen Perils of Urinary Catheters June 1, 2015 Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters The Case A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…

9937. Diagnostic Safety Improvement | PSNet
      psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
      July 21, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Safety Improvement  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNe…

9938. PSNet Curated Library (pdf file)
      psnet.ahrq.gov/print/pdf/node/854855
      January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Patient as a Team Member in Clinical Care Curated Library Foundations Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving Patient Safety. Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, F…

9939. Technology as a Tool for Improving Patient Safety | PSNet
      psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
      April 26, 2023 - Annual Perspective Technology as a Tool for Improving Patient Safety A Jay Holmgren, Susan McBride,Bryan Gale, Sarah Mossburg | March 29, 2023  View more articles from the same authors. Citation Text: Holmgren AJ, McBride S, Gale B, et al. Technology as a …

9940. One Toxic Drug Is Not Like Another | PSNet
      psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
      October 02, 2019 - SPOTLIGHT CASE One Toxic Drug Is Not Like Another Citation Text: Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTe…