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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867653/psn-pdf
    February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evoluti…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838197/psn-pdf
    September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. September 28, 2022 Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022. https://psnet.…
  3. psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
    October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49768/psn-pdf
    September 01, 2016 - A Pill Organizing Plight September 1, 2016 McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/pill-organizing-plight Case Objectives Identify patients at high risk for adverse drug events. List drugs that are considered inappropriate in older patients. …
  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
    January 01, 2022 - Spotlight Spotlight Intraosseous Line Extravasation in a Pediatric Trauma Patient Source and Credits • This presentation is based on the April 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: David Barnes, MD and Joseph Yoon, MD o…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836892/psn-pdf
    April 07, 2022 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department April 7, 2022 https://psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely- intensive-care Summary An increasing volume…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49566/psn-pdf
    July 01, 2008 - What Was in Those Platelets? July 1, 2008 Yomtovian R. What Was in Those Platelets? . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/what-was-those-platelets The Case A 47-year-old woman was admitted to the hospital for complex spinal surgery. The surgery went well without complications, and postoperativel…
  8. psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…
  9. 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…
  10. psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
    November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. Citation Text: Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867850/psn-pdf
    February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/persp…
  12. psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
    January 01, 2015 - without standardization, baseline performance measurement has so much variation that it is difficult to determine
  13. psnet.ahrq.gov/perspective/application-safety-ii-principles
    August 28, 2024 - looking at the events retrospectively with root cause analysis (RCA) or apparent cause analysis (ACA) to determine
  14. psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
    January 12, 2022 - reducing the risk of adverse events during the pandemic, researchers and policymakers will need to determine
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60242/psn-pdf
    March 01, 2021 - Enhanced provision of evidence-based care: Data from the EMR and patient reports were evaluated to determine
  16. psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
    August 28, 2024 - looking at the events retrospectively with root cause analysis (RCA) or apparent cause analysis (ACA) to determine
  17. psnet.ahrq.gov/perspective/conversation-susan-smith-md
    August 01, 2019 - scribes requires collaboration among several health care organization stakeholders: administration to determine
  18. psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
    January 12, 2022 - reducing the risk of adverse events during the pandemic, researchers and policymakers will need to determine
  19. psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
    January 01, 2008 - recommends that certain initiatives be incorporated into our Annual Corporate Accountabilities, which determine
  20. psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
    January 01, 2015 - without standardization, baseline performance measurement has so much variation that it is difficult to determine

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