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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867672/psn-pdf
    February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations February 26, 2025 Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. 2025. https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
  2. psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
    September 27, 2023 - SPOTLIGHT CASE Missed Opportunities for Suicide Risk Assessment Citation Text: Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation For…
  3. psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
    April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010  Also Read an Essay Citation Text: In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
  4. psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
    December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride Citation Text: Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Form…
  5. psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
    October 02, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case Citation Text: Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US …
  6. psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
    June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL Apri…
  7. psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
    September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? Ashish K. Jha, MD, MPH | September 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Jha AK. What Can the Rest of the Heal…
  8. psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
    January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only Spotlight Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism Source and Credits • This presentation is based on the February 2021 AHRQ WebM&M Spotlight Case o See the full article at ht…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850673/psn-pdf
    June 14, 2023 - In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm June 14, 2023 Johnson B. In Conversation with.. Beverley H. Johnson about The Role of Patient's Family In Reducing Harm. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-r…
  10. AHRQ PSNet Webinar (pdf file)

    psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
    January 01, 2025 - AHRQ PSNet Webinar AHRQ PSNet Webinar Making Healthcare Safer (MHS) IV: Rapid Response Systems and Opioid Stewardship February 10, 2025 Agenda 2 • Logistics • Introduction to the Making Healthcare Safer (MHS) IV Reports • Report 1 – Rapid Response Systems ► Discussion ► PSNet Resources • Report 2 – Opioi…
  11. psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
    October 01, 2007 - Making Just Culture a Reality: One Organization's Approach Alison H. Page, MS, MHA | October 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [in…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836840/psn-pdf
    April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE April 7, 2022 https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and- implements-methods Summary Venous thromboembolism (…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74830/psn-pdf
    June 01, 2022 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications February 23, 2022 https://psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-co…
  14. psnet.ahrq.gov/web-mm/stroke-error
    February 01, 2016 - SPOTLIGHT CASE A Stroke of Error Citation Text: Barrett KM. A Stroke of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
  15. psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
    January 29, 2021 - SPOTLIGHT CASE Intraoperative Awareness during Rhinoplasty Citation Text: Bohringer C, Toor J. Intraoperative Awareness during Rhinoplasty. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837913/psn-pdf
    August 31, 2022 - Miscommunication During the Interhospital Transport of a Critically Ill Child August 31, 2022 Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-c…
  17. psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
    September 27, 2023 - SPOTLIGHT CASE Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations Citation Text: Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
  18. psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
    April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance Lance L. Roberts, MS; Marcia M. Ward, PhD; Thomas C. Evans, MD | April 1, 2010  Also Read a Conversation View more articles from the same authors. …
  19. psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
    September 01, 2012 - Preparing for Health Reform: The Federal Government and the Nursing Workforce Peter I. Buerhaus, PhD, RN | September 1, 2012  Also Read a Conversation View more articles from the same authors. Citation Text: Buerhaus P. Preparing for Health Reform: The Federal G…
  20. psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
    March 27, 2024 - Miscommunication During the Interhospital Transport of a Critically Ill Child Citation Text: Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human …

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