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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
Citation Text:
In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - SPOTLIGHT CASE
Total Parenteral Nutrition, Multifarious Errors
Citation Text:
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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…
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psnet.ahrq.gov/node/865466/psn-pdf
March 27, 2024 - Equity in Patient Safety
March 27, 2024
Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/equity-patient-safety
Introduction
Safety and equity are among the central components that determine quality of care, according to nonprofit
advisory agencies l…
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - SPOTLIGHT CASE
Monitoring Fetal Health
Citation Text:
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Google Scholar BibTeX EndNot…
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - Premature Closure: Was It Just Syncope?
November 25, 2020
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
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psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md
February 26, 2025 - In Conversation With… Shantanu Nundy, MD
July 1, 2018
Citation Text:
In Conversation With… Shantanu Nundy, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:…
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psnet.ahrq.gov/node/857061/psn-pdf
November 27, 2023 - In Conversation with... Joan Stanley about The Role of
Undergraduate Nursing Education in Patient Safety
November 27, 2023
Stanley J. In Conversation with.. Joan Stanley about The Role of Undergraduate Nursing Education in
Patient Safety . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-joa…
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH
September 28, 2022
In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
Editor’s Note: Freya Spielberg, MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social
enterp…
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - In Conversation With… Gordon Schiff, MD
July 1, 2018
Citation Text:
In Conversation With… Gordon Schiff, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - In Conversation With… Gordon Schiff, MD
July 1, 2018
In Conversation With… Gordon Schiff, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
Editor's note: Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research
and Practice, Associate Pr…
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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/33789/psn-pdf
August 01, 2015 - In Conversation With… Robert M. Wachter, MD
August 1, 2015
In Conversation With… Robert M. Wachter, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
Editor's note: Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF,
where he also …
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Samantha Brown…
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psnet.ahrq.gov/perspective/equity-patient-safety
September 24, 2024 - Annual Perspective
Equity in Patient Safety
Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD
| March 27, 2024
View more articles from the same authors.
Citation Text:
Thomas A, Lee M, Mossburg S. Equity in Patient Safety. …
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon
Citation Text:
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy
Position for Laparoscopic Gynecological Surgery
July 10, 2024
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic
Gynecological Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…
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psnet.ahrq.gov/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - SPOTLIGHT CASE
Robotic Surgery: Risks vs. Rewards
Citation Text:
Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Googl…
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - Nurses learn the “Five Rights of
Medication Administration”25 but some experts propose that all providers