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  1. psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
    February 26, 2025 - In Conversation With… Gordon Schiff, MD July 1, 2018  Citation Text: In Conversation With… Gordon Schiff, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …
  2. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
    January 01, 2024 - Spotlight Spotlight Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Source and Credits • This presentation is based on the March 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: Christian Bohringer, MBBS, …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865429/psn-pdf
    April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery April 24, 2024 Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33861/psn-pdf
    July 01, 2018 - In Conversation With… Gordon Schiff, MD July 1, 2018 In Conversation With… Gordon Schiff, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-gordon-schiff-md Editor's note: Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, Associate Pr…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73102/psn-pdf
    July 01, 2022 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use March 31, 2021 https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail- community-dwelling Summary Care management staff (such …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33804/psn-pdf
    March 03, 2016 - In Conversation With… Paul McGann, MD March 1, 2016 In Conversation With… Paul McGann, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for Medicare & Medicaid Services (CMS). He…
  7. psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
    June 28, 2023 - SPOTLIGHT CASE A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care Citation Text: Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
  8. 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…
  9. psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
    February 05, 2020 - Hypoxic Gas Supply from Cross-Connected Pipelines Citation Text: Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google S…
  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. psnet.ahrq.gov/web-mm/pill-organizing-plight
    June 19, 2018 - SPOTLIGHT CASE A Pill Organizing Plight Citation Text: McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTe…
  12. psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery Citation Text: Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
  13. psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
    November 25, 2020 - SPOTLIGHT CASE A Laceration that Needed a Proper Exam, Not an X-Ray Citation Text: Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Cit…
  14. psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
    January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon Citation Text: Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
  15. psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
    November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH November 1, 2008  Also Read an Essay Citation Text: In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 200…
  16. psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
    September 13, 2023 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 31…
  17. psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
    September 01, 2014 - In Conversation With… Rosemary Gibson, MSc September 1, 2014  Also Read an Essay Citation Text: In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
  18. psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
    March 30, 2020 - Making Healthcare Safer III Report March 30, 2020  Also Read the Conversation View more articles from the same authors. Citation Text: Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. Rockville (MD): Agency for Health…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848124/psn-pdf
    April 26, 2023 - In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring April 26, 2023 In Conversation with.. Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-ab…
  20. psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
    November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions Lindsay E. Nicolle, MD | November 1, 2008  Also Read a Conversation View more articles from the same authors. Citation Text: Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Pr…

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