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psnet.ahrq.gov/node/836841/psn-pdf June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…  
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psnet.ahrq.gov/node/49798/psn-pdf July 01, 2017 - Pseudo-obstruction But a Real Perforation
July 1, 2017
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
Case Objectives
Recognize acute colonic pseudo-obstruction and implement a medical management plan.
Ide…  
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors May 22, 2024 - SPOTLIGHT CASE
         
 How Do Providers Recover From Errors? 
 
 
 
 
 Citation Text: 
 West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. 
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psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error August 02, 2015 - SPOTLIGHT CASE
         
 Delay in Initiating Antibiotics Results in Fatal Error 
 
 
 
 
 Citation Text: 
 Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. 
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong May 29, 2024 - Getting the Diagnosis Both Right and Wrong 
 
 
 
 
 Citation Text: 
 Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. 
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psnet.ahrq.gov/node/848108/psn-pdf April 26, 2023 - Only one case required cardiopulmonary
resuscitation and no deaths were reported.3
This case is an 
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety May 01, 2012 - System,  the Institute of Medicine estimated that avoidable medical errors contribute to 44,000–98,000 deaths 
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psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms May 01, 2012 - System,  the Institute of Medicine estimated that avoidable medical errors contribute to 44,000–98,000 deaths 
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psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence March 27, 2024 - 28, 2022 
 
 
 
 
 
 
 
 
 
 
 Classifying errors in preventable and potentially preventable trauma deaths 
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psnet.ahrq.gov/node/73334/psn-pdf August 01, 2024 - An Inadvertent Bolus of Norepinephrine.
May 26, 2021
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…  
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine December 04, 2016 - SPOTLIGHT CASE
         
 An Inadvertent Bolus of Norepinephrine. 
 
 
 
 
 Citation Text: 
 Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. 
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 F…  
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis February 26, 2025 - The Evolution of Root Cause Analysis 
 Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025 
                       
 Also Read the Conversation  
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Behrhorst J, Gale B, Van CM. Th…  
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis 
 Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025 
                       
 
 
 
 Also Read the Essay  
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation T…  
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psnet.ahrq.gov/perspective/conversation-richard-kronick-phd February 01, 2014 - than would have occurred if the 2010 rate had remained unchanged, and, more importantly, 87,000 fewer deaths 
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psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain January 01, 2006 - Accidental deaths, saved lives, and improved quality. 
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psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md September 01, 2016 - One concerning study reviewed 32 cases that ended in catastrophic outcomes, including deaths and malpractice 
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psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph September 01, 2008 - These errors were responsible for the deaths of three newborn infants at Methodist Hospital in Indianapolis 
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psnet.ahrq.gov/perspective/conversation-withjack-barker-phd January 01, 2006 - Accidental deaths, saved lives, and improved quality. 
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psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety September 01, 2008 - These errors were responsible for the deaths of three newborn infants at Methodist Hospital in Indianapolis 
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psnet.ahrq.gov/web-mm/compare-and-contrast July 16, 2019 - SPOTLIGHT CASE
         
 Compare and Contrast 
 
 
 
 
 Citation Text: 
 Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. 
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