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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - SPOTLIGHT CASE
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
Citation Text:
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
May 05, 2025 - Breadcrumb
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Created By: Lorri Zipperer, Cybraria…
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - SPOTLIGHT CASE
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Citation Text:
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - SPOTLIGHT CASE
The Perils of Cross Coverage
Citation Text:
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
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Google Scholar BibTeX En…
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psnet.ahrq.gov/node/73899/psn-pdf
September 29, 2021 - These guidelines encouraged providers to “prescribe the lowest effective
dosage” and recommended that
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - These guidelines encouraged providers to “prescribe the lowest effective dosage” and recommended that
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psnet.ahrq.gov/sites/default/files/2020-04/final_april-spotlight-implicit_biases_04.02.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Implicit Biases, Interprofessional
Communication, and Power
Dynamics
Source and Credits
• This presentation is based on the April 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Erin Stephany Sanchez, MD, Melody Tran-
Reina, MD, Kupi…
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - Annual Perspective
Annual Perspective: Topics in Medication Safety
March 31, 2022
View more articles from the same authors.
Citation Text:
Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
March 01, 2015 - In Conversation With… Brian Jarman, PhD
March 1, 2015
Also Read an Essay
Citation Text:
In Conversation With… Brian Jarman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy…
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care
Following Cesarean Delivery.
November 25, 2020
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean
Delivery. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…
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psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
February 26, 2025 - In Conversation with...Brent C. James, MD, MStat
February 1, 2011
Citation Text:
In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011.In Conversation with...Brent C. James, MD, MStat. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
April 01, 2005 - In Conversation with…Christopher P. Landrigan, MD
April 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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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…
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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.
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Format:
…
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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 …
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psnet.ahrq.gov/node/846975/psn-pdf
March 28, 2023 - In Conversation with... Christie Allen about Maternal
Safety and Perinatal Mental Health
March 28, 2023
In Conversation with.. Christie Allen about Maternal Safety and Perinatal Mental Health. PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal…
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNot…
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx
Spotlight
Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes
Source and Credits
• This presentation is based on the April 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/we…
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH
September 28, 2022
In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
Editor’s Note: Freya Spielberg, MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social
enterp…
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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…