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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - In Conversation with Timothy Vogus about High
Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization
(HRO) Principles and Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/persp…
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
January 01, 2022 - Spotlight
Spotlight
Perioperative Anaphylaxis After Insertion of
a Latex Drain in a Patient with Known Latex
Allergy
Source and Credits
• This presentation is based on the August 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by K…
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - purposes, from raising safety awareness among staff, to getting a baseline assessment of culture, to examining
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psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
December 01, 2005 - An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up
Robert M. Wachter, MD | June 1, 2012
View more articles from the same authors.
Citation Text:
Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. …
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
September 28, 2022 - Examining the functions and goals of primary care illustrates how they relate to these healthcare quality
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - Examining the functions and goals of primary care illustrates how they relate to these healthcare quality
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psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
March 30, 2020 - Making Healthcare Safer III Report
March 30, 2020
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. Rockville (MD): Agency for Health…
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - SPOTLIGHT CASE
Falling Through the Crack (in the Bedrails)
Citation Text:
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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F…
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psnet.ahrq.gov/node/50755/psn-pdf
December 18, 2019 - The Need to Eat
December 18, 2019
Widaman AM. The Need to Eat. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/need-eat
The Case
A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder
caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication
Citation Text:
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - In Conversation With... David Gruen, MD
January 31, 2020
Also Read the Essay
Citation Text:
In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.In Conversation With... David Gruen, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research an…
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Hea…
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to
Complications and Poor Follow-up
July 31, 2023
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications
and poor follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes.
April 26, 2023
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
Disclosure of Relevant Financial R…
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - In Conversation With… Jack Needleman, PhD
September 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… Jack Needleman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012…
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psnet.ahrq.gov/web-mm/need-eat
February 10, 2021 - The Need to Eat
Citation Text:
Widaman AM. The Need to Eat. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - SPOTLIGHT CASE
Diagnosing HIV-It Doesn't Take a Brain Surgeon
Citation Text:
Chou R. Diagnosing HIV-It Doesn't Take a Brain Surgeon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
…
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psnet.ahrq.gov/node/836850/psn-pdf
March 31, 2022 - Annual Perspective: Topics in Medication Safety
March 31, 2022
Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
Introduction
Issues with medication management and errors in medi…
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psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
February 01, 2012 - In Conversation With… Lawrence Smith, MD
February 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… Lawrence Smith, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
…
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psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
July 06, 2022 - Undiagnosed Vaginal Bleeding
Citation Text:
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…