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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience
William S. Krimsky, MD | November 1, 2005
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Citation Text:
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…
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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - SPOTLIGHT CASE
Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy
Citation Text:
Kelly KJ. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Resear…
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psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety
Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN | September 1, 2008
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Citation Text:
Rothschild JM, Keohane C. The Role of Bar Coding and Sm…
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psnet.ahrq.gov/node/73902/psn-pdf
September 29, 2021 - Dangers of Missing an Epidural Abscess: Multiple Visits
and Delayed Diagnosis with a Severely Negative Outcome
September 29, 2021
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed
Diagnosis with a Severely Negative Outcome. PSNet [internet]. 2021.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/837324/psn-pdf
July 08, 2022 - A Statewide Collaborative to Support Vaginal Birth and
Reduce Unnecessary Cesarean Deliveries
July 8, 2022
https://psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-
cesarean-deliveries
Summary
Started in response to rising maternal morbidity and mortality rates in …
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psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
March 01, 2017 - In Conversation With… Mary Dixon-Woods, DPhil
March 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Mary Dixon-Woods, DPhil. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show
March 01, 2013 - The Literature on Health Care Simulation Education: What Does It Show?
David A. Cook, MD, MHPE | March 1, 2013
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Citation Text:
Cook DA. The Literature on Health Care Simulation Education: What Do…
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psnet.ahrq.gov/node/867986/psn-pdf
March 24, 2025 - In Conversation with Edwin Boudreaux about Suicide
Prevention
March 24, 2025
Boudreaux E, Gale B, Mossburg SE. In Conversation with Edwin Boudreaux about Suicide Prevention.
PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
Editor’s note: Edwin Boudre…
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psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
November 13, 2024 - Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area
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June 12, 2020
Innovation
…
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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
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Citation Text:
Singer SJ. Our Maturing Understanding of Safety C…
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psnet.ahrq.gov/node/836941/psn-pdf
April 27, 2022 - Post-Acute Transitional Services: Safety in Home-Based
Care Programs
April 27, 2022
McElroy V, Ordona RB, Bakerjian D. Post-Acute Transitional Services: Safety in Home-Based Care
Programs. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
Backgr…
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psnet.ahrq.gov/perspective/conversation-jane-brice-md-mph
May 01, 2019 - In Conversation With… Jane Brice, MD, MPH
May 1, 2019
Also Read an Essay
Citation Text:
In Conversation With… Jane Brice, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Co…
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psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
August 01, 2018 - In Conversation With… Matthew Weinger, MD
August 1, 2018
Also Read an Essay
Citation Text:
In Conversation With… Matthew Weinger, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
…
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psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
May 01, 2019 - Safety in the Prehospital Emergency Medical Services Setting
P. Daniel Patterson, PhD, NRP, and Donald M. Yealy, MD | May 1, 2019
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Citation Text:
Patterson DP, Yealy DM. Safety in the Prehospital…
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psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
April 24, 2024 - Post-Acute Transitional Services: Safety in Home-Based Care Programs
Citation Text:
McElroy V, Ordona RB, Bakerjian D. Post-Acute Transitional Services: Safety in Home-Based Care Programs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - SPOTLIGHT CASE
The Risks of a Malpositioned Gastrostomy Tube and Poor Communication
Citation Text:
Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - SPOTLIGHT CASE
Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome
Citation Text:
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…
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psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - Annual Perspective
AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety
March 30, 2021
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Citation Text:
Stocking JC, Sandrock C, Fitall E, et al. AHRQ PSNet Annual Perspective: Impact of the…
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psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
August 01, 2018 - How Does Health Care Simulation Affect Patient Care?
Joseph O. Lopreiato, MD, MPH | August 1, 2018
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Citation Text:
Lopreiato JO. How Does Health Care Simulation Affect Patient Care?. PSNet [inter…
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - Spotlight
Spotlight
Lost in Transitions of Care: Managing an
Opioid-Dependent Patient with Frequent
Hospitalizations
Source and Credits
• This presentation is based on the September 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary …