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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/node/49704/psn-pdf
March 01, 2014 - Late Anemia Following Rh Disease in a Newborn
March 1, 2014
Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
The Case
A full-term neonate was delivered uneventfully to an Rh-negative woman who had re…
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psnet.ahrq.gov/web-mm/did-we-forget-something
April 28, 2021 - Did We Forget Something?
Citation Text:
Gibbs VC. Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/49572/psn-pdf
October 01, 2008 - Mistaken Identity
October 1, 2008
Hall LW. Mistaken Identity. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mistaken-identity
The Case
An 85-year-old Cantonese-speaking woman was admitted to the medical service with altered mental status
and a reported fall. After finding tenderness in her left hip, the p…
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psnet.ahrq.gov/node/33629/psn-pdf
March 01, 2006 - What Does Simulation Add to Teamwork Training?
March 1, 2006
Gaba DM. What Does Simulation Add to Teamwork Training? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
Editor's Note: In these point–counterpoint articles, Drs. Pratt and Sachs of Beth Israel Deacones…
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psnet.ahrq.gov/web-mm/lp-or-not-lp
February 01, 2018 - To LP or Not LP
Citation Text:
Landrigan CP. To LP or Not LP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/60744/psn-pdf
July 29, 2020 - The NSTEMI Curbside Consultation
July 29, 2020
Villablanca AC, Wong GX. The NSTEMI Curbside Consultation. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for
Continuing Medical E…
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psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
August 01, 2007 - The PeaceHealth Governance Journey in Support of Quality and Safety
John L. Haughom,
MD | August 1, 2007
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Citation Text:
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and …
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psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d
October 24, 2021 - In Conversation With... Georgia Galanou Luchen, Pharm. D.
October 24, 2021
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Citation Text:
In Conversation With.. Georgia Galanou Luchen, Pharm. D. PSNet [internet]. 2021.In Conversation With... Georgia Galanou Luchen, Pharm. D.. PSNet [interne…
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - In Conversation with...Mark Chassin, MD, MPP, MPH
April 1, 2009
Also Read an Essay
Citation Text:
In Conversation with..Mark Chassin, MD, MPP, MPH . PSNet [internet]. 2009.In Conversation with...Mark Chassin, MD, MPP, MPH . PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.In Conversation with...James L. Reinertsen, MD. PSNet [internet]. Rockville (MD): Agency for Heal…
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - In Conversation with Eric Thomas about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement
Eric Thomas, Sarah Mossburg, Merton Lee | September 24, 2024
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Citatio…
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing
Citation Text:
Giannini J, Wong M, Dager W, et al. Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - Maternal Safety
January 31, 2024
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/maternal-safety
Originally published in 2018 by researchers at the University of California, San Francisco. Updated in
February 2024 by Marla Shauer, PhD(c), MSN, CNM, Amy Nichols,…
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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - Becoming a Patient Safety Organization
Rory Jaffe, MD, MBA | July 1, 2011
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Citation Text:
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. Rockville (MD): Agency for Healthcare …
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please
Teryl K. Nuckols, MD, MSHS | September 1, 2011
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Citation Text:
Nuckols TK. Incident Reporting: More Attention to the …
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psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
May 01, 2013 - Strengthening the Business Case for Patient Safety
Peter K. Lindenauer, MD, MSc | May 1, 2013
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Citation Text:
Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. …
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
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psnet.ahrq.gov/node/867849/psn-pdf
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet
[internet]. 2025.
https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
In To Err I…
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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Check the Anesthesia Machine
Citation Text:
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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