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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
    January 01, 2024 - Spotlight Spotlight Laceration that Needed a Proper Exam, Not an X-Ray Source and Credits • This presentation is based on the January 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: Jazmin A. Wander, MD and David K. Barnes, MD, F…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49491/psn-pdf
    September 01, 2005 - Time of Death? September 1, 2005 Taekman JM, Wright MC. Time of Death? PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/time-death The Case An 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD), was found pulseless and cyanotic in her hospital bed. A code was ca…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72613/psn-pdf
    December 22, 2020 - In Conversation With... Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD December 22, 2020 In Conversation With.. Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f- w…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33760/psn-pdf
    February 01, 2014 - In Conversation With… Enrico Coiera, MB, BS, PhD February 1, 2014 In Conversation With… Enrico Coiera, MB, BS, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd Editor's note: Enrico Coiera, MB, BS, PhD, is a professor and director of the Centre for Health Informa…
  5. psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
    July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 29, 2024 View more articles from the same authors. Inno…
  6. 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…
  7. psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
    May 01, 2005 - Delayed Breast Cancer Diagnosis: A False Sense of Security. Citation Text: Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cita…
  8. psnet.ahrq.gov/web-mm/time-death
    January 03, 2017 - Time of Death? Citation Text: Taekman JM, Wright MC. Time of Death?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
  9. 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 …
  10. 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…
  11. psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx Spotlight Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Source and Credits • This presentation is based on the June 2023 AHRQ WebM&M Spotlight Case o See…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33776/psn-pdf
    January 01, 2015 - In Conversation With… Mark Graban, MS, MBA January 1, 2015 In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba Editor's note: Mark Graban, MS, MBA, is an internationally recognized expert in Lean Healthcare, which has become one of…
  13. psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
    April 08, 2019 - SPOTLIGHT CASE The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy Citation Text: Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcar…
  14. psnet.ahrq.gov/perspective/lesson-vas-team-training-program
    November 01, 2011 - Lesson from the VA's Team Training Program Julia Neily, RN, MS, MPH; Peter D. Mills, PhD, MS; Lisa M. Mazzia, MD; and Douglas E. Paull,MD | November 1, 2011  Also Read a Conversation View more articles from the same authors. Citation Text: Neily J, Mills PD, Pa…
  15. psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
    March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety Sara J. Singer, MBA, PhD | March 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Singer SJ. Our Maturing Understanding of Safety C…
  16. psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
    November 01, 2011 - In Conversation With… Eduardo Salas, PhD November 1, 2011  Also Read an Essay Citation Text: In Conversation With… Eduardo Salas, PhD . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.…
  17. psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
    April 01, 2018 - Patient Safety During Hospital Discharge Katherine Liang and Eric Alper, MD | April 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. Rockville…
  18. psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
    April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM April 1, 2018  Also Read an Essay Citation Text: In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
  19. psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
    November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn Citation Text: Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49565/psn-pdf
    July 01, 2008 - Wrong Route for Nutrients July 1, 2008 Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/wrong-route-nutrients The Case An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6 months. He had lost weight and d…

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