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  1. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-469
    December 31, 2024 - January 8, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports…

  2. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025  Also Read the Essay View more articles from the same authors. Citation T…

  3. The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/evolution-root-cause-analysis
    February 26, 2025 - The Evolution of Root Cause Analysis Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Behrhorst J, Gale B, Van CM. Th…

  4. In Conversation with...Patrick S. Romano, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
    July 10, 2024 - In Conversation with...Patrick S. Romano, MD, MPH November 1, 2010  Citation Text: In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.In Conversation with...Patrick S. Romano, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

  5. In Conversation With… Timothy B. McDonald, MD, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
    February 26, 2025 - In Conversation With… Timothy B. McDonald, MD, JD April 1, 2019  Citation Text: In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy C…

  6. May I Have Another?—Medication Error | PSNet

    psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
    March 01, 2009 - May I Have Another?—Medication Error Citation Text: Wolf MS. May I Have Another?—Medication 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. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852698/psn-pdf
    August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation August 30, 2023 https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and- diagnostic-accuracy Summary Addressing diagnostic errors to improve outcomes and patient safety h…

  8. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia | PSNet

    psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
    August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia Citation Text: Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33803/psn-pdf
    January 01, 2015 - In Conversation With… Richard Kronick, PhD February 1, 2014 In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since August 2013 …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865412/psn-pdf
    March 27, 2024 - Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation March 27, 2024 Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatmen…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73336/psn-pdf
    May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers May 26, 2021 Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers The Case  …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49684/psn-pdf
    May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical Error May 1, 2013 Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error Case Objectives Appreciate that chemotherapy a…

  13. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-11/spotlight_case_neurological_red_flags_final.pptx
    January 01, 2024 - Spotlight Spotlight Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache 1 Source and Credits This presentation is based on the November 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Jonatha…

  14. Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache | PSNet

    psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
    February 08, 2023 - SPOTLIGHT CASE Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache Citation Text: Edlow J. Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …

  15. 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…

  16. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. | PSNet

    psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
    August 31, 2022 - SPOTLIGHT CASE Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. Citation Text: Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

  17. Privacy or Safety? | PSNet

    psnet.ahrq.gov/web-mm/privacy-or-safety
    December 01, 2011 - SPOTLIGHT CASE Privacy or Safety? Citation Text: Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

  18. Right Regimen, Wrong Cancer: Patient Catches Medical Error | PSNet

    psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
    August 01, 2006 - SPOTLIGHT CASE Right Regimen, Wrong Cancer: Patient Catches Medical Error Citation Text: Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…

  19. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation | PSNet

    psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
    September 27, 2023 - SPOTLIGHT CASE Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation Citation Text: Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. Rockville (MD): Agency for Health…

  20. The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation | PSNet

    psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
    April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL August 30, 2023 View more articles from the…
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