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  1. Dying in the Hospital With Advanced Dementia | PSNet

    psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
    November 01, 2016 - SPOTLIGHT CASE Dying in the Hospital With Advanced Dementia Citation Text: Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Ci…

  2. In Conversation With… Lucian Leape, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-lucian-leape-md
    June 12, 2019 - In Conversation With… Lucian Leape, MD April 1, 2015  Citation Text: In Conversation With… Lucian Leape, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33859/psn-pdf
    June 01, 2018 - In Conversation With… Richard Hoppmann, MD June 1, 2018 In Conversation With… Richard Hoppmann, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md Editor's note: Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor of Medicine, and Dire…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836794/psn-pdf
    March 31, 2022 - A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. March 31, 2022 Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-c…

  5. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
    January 01, 2022 - Spotlight Spotlight A Case of Mistaken Capacity: Why a Thorough Psychosocial History Can Improve Care Source and Credits • This presentation is based on the March 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: Katrina Pasao, MD…

  6. 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…

  7. Psn-Pdf (pdf file)

    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…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846126/psn-pdf
    March 09, 2023 - Medication Handling and Compounding Errors in the Operating Room. March 15, 2023 Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room The Case A 62-y…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836879/psn-pdf
    April 27, 2022 - In Conversation With... Michael L. Millenson April 27, 2022 In Conversation With.. Michael L. Millenson. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-michael-l-millenson December 16, 2021 Editor’s note: Michael L. Millenson is the President of Health Quality Advisors LLC, author of the c…

  10. Spotlight

    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…

  11. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/848754
    January 01, 2025 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Implementation of Patient Safety Projects Curated Library Foundations Leading change: why transformation efforts fail. Kotter JP. Harvard Bus Rev  1995;73(2);59-67. Kotter, a professor at Harvard Business School, outlines the eight stages …

  12. Robotic Surgery: Risks vs. Rewards | PSNet

    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. Copy Citation Format: Googl…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857059/psn-pdf
    November 29, 2023 - The Risks of a Malpositioned Gastrostomy Tube and Poor Communication November 29, 2023 Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication Disclosure of Relevant Financial …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60721/psn-pdf
    July 21, 2020 - Special Edition Perspective: Technology Responses to COVID-19 July 21, 2020 Marcin JP, Cohen NM, Lowery C, et al. Special Edition Perspective: Technology Responses to COVID-19. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19 Editor’s note: This …

  15. COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care | PSNet

    psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
    February 24, 2022 - COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care Citation Text: Kalenderian E, Spallek H, Franklin A, et al. COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department o…

  16. Innovations in Promoting Hand Hygiene Compliance | PSNet

    psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
    May 01, 2014 - Innovations in Promoting Hand Hygiene Compliance Alexandre R. Marra, MD and Michael B. Edmond, MD, MPH, MPA | May 1, 2014  Also Read a Conversation View more articles from the same authors. Citation Text: Marra AR, Edmond MB. Innovations in Promoting Hand Hygie…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33827/psn-pdf
    February 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS February 1, 2017 Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps Perspective Ten years ago, the Ag…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49503/psn-pdf
    February 01, 2006 - Workaround Error February 1, 2006 Pape T. Workaround Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/workaround-error The Case A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospita…

  19. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
    October 01, 2010 - Spotlight Case July 2008 Spotlight Case October 2010 Dangerous Dialysis * * Source and Credits This presentation is based on the October 2010 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49866/psn-pdf
    June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the Operating Room June 1, 2019 Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room The Case A 43-year-old woman was admi…
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