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  1. psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
    March 01, 2018 - SPOTLIGHT CASE Difficult Encounters: A CMO and CNO Respond Citation Text: Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49564/psn-pdf
    July 01, 2008 - Dependence vs. Pain July 1, 2008 Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dependence-vs-pain Case Objectives Define opioid dependence and opioid withdrawal syndrome. Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid Withdra…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60268/psn-pdf
    April 29, 2020 - Complications of ECMO During Transport April 29, 2020 Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport The Case A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with acute on chro…
  4. 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…
  5. psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
    November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. Citation Text: Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49483/psn-pdf
    June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…
  7. psnet.ahrq.gov/web-mm/getting-root-matter
    September 01, 2005 - SPOTLIGHT CASE Getting to the Root of the Matter Citation Text: Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Schola…
  8. psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Intraoperative Awareness during Rhinoplasty 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Christian Bohringer MBBS and Jaijeet Toor MD AHRQ WebM&M Edit…
  9. psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
    June 09, 2021 - Book/Report Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Citation Text: Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Farnborough, UK: Healthcare Safety Investigation Branch; June 2021. Copy Citation …
  10. psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-do-and-how-fix-it
    November 20, 2019 - Newspaper/Magazine Article Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Citation Text: Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Park A. Time Magazine. January 24, 2019. Copy Citation…
  11. psnet.ahrq.gov/issue/american-college-radiology-white-paper-mr-safety-2004-update-and-revisions
    September 28, 2022 - Clinical Guideline American College of Radiology White Paper on MR Safety: 2004 Update and Revisions. Citation Text: doi:10.2214/ajr.182.5.182111. Copy Citation Format: DOI BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …
  12. psnet.ahrq.gov/issue/seeing-systems-health-care-organizations
    January 25, 2023 - Commentary Seeing systems in health care organizations. Citation Text: Friedman LH, King JB, Bella D. Seeing systems in health care organizations. Physician Exec. 2007;33(4):20-9. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
  13. psnet.ahrq.gov/issue/strategies-improve-patient-safety-final-report-congress-required-patient-safety-and-quality
    June 21, 2016 - Book/Report Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005. Citation Text: Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.…
  14. psnet.ahrq.gov/issue/communication-and-teamwork-patient-care-how-much-can-we-learn-aviation
    August 12, 2019 - Review Communication and teamwork in patient care: how much can we learn from aviation? Citation Text: Lyndon A. Communication and teamwork in patient care: how much can we learn from aviation? J Obstet Gynecol Neonatal Nurs. 2006;35(4):538-46. Copy Citation Format: Googl…
  15. psnet.ahrq.gov/issue/concept-analysis-systems-thinking
    August 20, 2018 - Review A concept analysis of systems thinking. Citation Text: Stalter AM, Phillips JM, Ruggiero JS, et al. A Concept Analysis of Systems Thinking. Nurs Forum. 2017;52(4):323-330. doi:10.1111/nuf.12196. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
  16. psnet.ahrq.gov/issue/thinking-fast-and-slow-medicine
    June 21, 2017 - Commentary Thinking fast and slow in medicine. Citation Text: Michel JB. Thinking fast and slow in medicine. Baylor U Med Center Proceed. 2019;33(1):123-125. doi:10.1080/08998280.2019.1674043. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
  17. psnet.ahrq.gov/issue/improving-patient-understanding-prescription-drug-label-instructions
    April 16, 2010 - Study Improving patient understanding of prescription drug label instructions. Citation Text: Davis TC, Federman AD, Bass PF, et al. Improving patient understanding of prescription drug label instructions. J Gen Intern Med. 2009;24(1):57-62. doi:10.1007/s11606-008-0833-4. Copy Citati…
  18. psnet.ahrq.gov/issue/documenting-day-discussion-ahead-crest-wave-creating-national-agenda-systemic-change-enhanced
    April 28, 2021 - Book/Report Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being. Citation Text: Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change …
  19. psnet.ahrq.gov/issue/junior-doctors-shifts-and-sleep-deprivation
    October 16, 2012 - Commentary Junior doctors' shifts and sleep deprivation. Citation Text: Murray A, Pounder R, Mather H, et al. Junior doctors' shifts and sleep deprivation. BMJ. 2005;330(7505):1404. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  20. psnet.ahrq.gov/issue/role-automation-complex-system-failures
    June 28, 2013 - Commentary The role of automation in complex system failures. Citation Text: Perry SJ, Wears RL, Cook RI. The role of automation in complex system failures. J Patient Saf. 2005;1(1):56-61. https://journals.lww.com/journalpatientsafety/Fulltext/2005/03000/The_Role_of_Automation_in_Compl…

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