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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT
| April 24, 2024
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Leary KB. In Con…
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - Preparing for Health Reform: The Federal Government and the Nursing Workforce
Peter I. Buerhaus, PhD, RN | September 1, 2012
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Buerhaus P. Preparing for Health Reform: The Federal G…
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia
Citation Text:
Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE
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psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
December 18, 2024 - SPOTLIGHT CASE
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication
Citation Text:
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - SPOTLIGHT CASE
A Missed Bowel Perforation - the Importance of Diagnostic Reasoning
Citation Text:
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - Infection After Carpal Tunnel Surgery
August 28, 2024
Szabo RM. Infection After Carpal Tunnel Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
The Case
A woman presented for surgery on her right wrist as a treatment for carpal tunnel syndrome. There were no
repo…
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - Do Not Miss Sepsis Needles in Viral Haystacks!
March 27, 2024
Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accredit…
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective
Zahra Khudeira, PharmD | June 1, 2016
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Khudeira Z. Becoming a Certified Professional in Patient Safet…
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psnet.ahrq.gov/perspective/safety-and-medical-education
December 01, 2013 - Annual Perspective
Safety and Medical Education
Sumant Ranji, MD | January 1, 2014
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Ranji SR. Safety and Medical Education. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/node/850673/psn-pdf
June 14, 2023 - In Conversation with... Beverley H. Johnson about The
Role of Patient's Family In Reducing Harm
June 14, 2023
Johnson B. In Conversation with.. Beverley H. Johnson about The Role of Patient's Family In Reducing
Harm. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-r…
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psnet.ahrq.gov/node/74149/psn-pdf
January 07, 2022 - Multiple Missed Opportunities for Suicide Risk
Assessment in Emergency and Primary Care Settings
January 7, 2022
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and
Primary Care Settings. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/multiple-missed-opportu…
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only
Spotlight
Delay in Appropriate Diagnosis and
Treatment Leading to Death from
Pulmonary Embolism
Source and Credits
• This presentation is based on the February 2021 AHRQ WebM&M
Spotlight Case
o See the full article at ht…
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc
October 30, 2019
Citation Text:
In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health
Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for
Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - Sleep Deprivation Leads to Medication Error During
Spinal Epidural Anesthesia
August 30, 2023
Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-…
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psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
September 01, 2005 - Playing Well with Others: "Translocational Research" in Patient Safety
Robert M. Wachter, MD | September 1, 2005
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Citation Text:
Wachter R. Playing Well with Others: "Translocational Research" in…
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - Culture Clash No More: Integration and Coordination of
Disease Treatment and Palliative Care
November 30, 2021
Spero H, Usher AE, Howard B, et al. Culture Clash No More: Integration and Coordination of Disease
Treatment and Palliative Care . PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/culture-clash-no-mo…
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE)
Collaborative Studies and Implements Methods to Prevent
Avoidable Cases of Hospital Associated VTE
April 7, 2022
https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-
implements-methods
Summary
Venous thromboembolism (…