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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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psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
May 31, 2023 - In Conversation With… Vineet Arora, MD, MAPP
September 1, 2015
Citation Text:
In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
October 30, 2024 - The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
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psnet.ahrq.gov/node/836892/psn-pdf
April 07, 2022 - The University of Michigan Emergency Critical Care
Center (EC3) Provides Timely Intensive Care to Critically
Ill Patients in the Emergency Department
April 7, 2022
https://psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-
intensive-care
Summary
An increasing volume…
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psnet.ahrq.gov/node/49561/psn-pdf
May 01, 2008 - Diagnosing HIV-It Doesn't Take a Brain Surgeon
May 1, 2008
Chou R. Diagnosing HIV-It Doesn't Take a Brain Surgeon. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
Case Objectives
Describe the current epidemiology of HIV infection.
Identify the risk factors for HIV…
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - In Conversation With... Anjali Joseph, PhD, EDAC and
Molly M. Scanlon, PhD, FAIA, FACHA
June 30, 2021
In Conversation With.. Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-
…
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psnet.ahrq.gov/node/49682/psn-pdf
April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature
Closure and Anchoring in a Complicated Case
April 1, 2013
Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a
Complicated Case. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…
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psnet.ahrq.gov/node/49566/psn-pdf
July 01, 2008 - What Was in Those Platelets?
July 1, 2008
Yomtovian R. What Was in Those Platelets? . PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/what-was-those-platelets
The Case
A 47-year-old woman was admitted to the hospital for complex spinal surgery. The surgery went well
without complications, and postoperativel…
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - SPOTLIGHT CASE
Too Many Cooks in the Kitchen
Citation Text:
Dutton RP. Too Many Cooks in the Kitchen. 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/node/33857/psn-pdf
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
Editor's note: Dr. Blumenthal is President of the Commonwealth Fund and served as the National
Coordinator …
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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/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/node/33791/psn-pdf
September 01, 2015 - In Conversation With… Vineet Arora, MD, MAPP
September 1, 2015
In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
Editor's note: Vineet Arora, MD, MAPP, is Director of GME Clinical Learning Environment Innovation,
Associate Pr…
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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health
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…
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psnet.ahrq.gov/node/843150/psn-pdf
December 05, 2022 - In Conversation with... Connor Wesley, RN, BSN on
Patient Safety Concerns and the LGBTQ+ Population
February 1, 2023
In Conversation with.. Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ+ Population.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-connor-wesley-rn-bsn-patie…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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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.
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psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Affordable Housing Community Offers Seniors Onsite
Health Care Coordination and Support, Reducing Hospital
Admissions and Falls and Improving Resident Health
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-h…
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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 …