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psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
February 05, 2020 - Hypoxic Gas Supply from Cross-Connected Pipelines
Citation Text:
Bohringer C, Guemidjian A, Utter G. Hypoxic Gas Supply from Cross-Connected Pipelines. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
March 24, 2021 - SPOTLIGHT CASE
Pitfalls in Diagnosing Necrotizing Fasciitis
Citation Text:
Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. 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/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/perspective/conversation-j-bryan-sexton-phd-ma
February 26, 2025 - In Conversation With… J. Bryan Sexton, PhD, MA
August 1, 2013
Citation Text:
In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
January 29, 2021 - Misconnection Leading to Arterial Thrombosis
Citation Text:
Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - Annual Perspective
Ensuring Patient and Workforce Safety Culture in Healthcare
John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg
| March 27, 2024
View more articles from the same authors.
Citation Text:
Murray J, Sorra J, Gale B, et al. Ensuring Patient…
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meps.ahrq.gov/data_files/publications/st560/stat560.shtml
March 01, 2025 - Concentration of Healthcare Expenditures and Selected Characteristics of People with High Expenses, United States Civilian Noninstitutionalized Population, 2018-2022
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An official website of the Department…
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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…
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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/perspective/conversation-maureen-bisognano
February 26, 2025 - In Conversation With… Maureen Bisognano
June 1, 2015
Citation Text:
In Conversation With… Maureen Bisognano. 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/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - Medication Handling and Compounding Errors in the Operating Room.
Citation Text:
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating Room.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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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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psnet.ahrq.gov/node/49768/psn-pdf
September 01, 2016 - A Pill Organizing Plight
September 1, 2016
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/pill-organizing-plight
Case Objectives
Identify patients at high risk for adverse drug events.
List drugs that are considered inappropriate in older patients.
…
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meps.ahrq.gov/data_files/publications/st556/stat556.shtml
March 01, 2024 - Concentration of Healthcare Expenditures and Selected Characteristics of Persons With High Expenses, United States Civilian Noninstitutionalized Population, 2018-2021
Skip to main content
An official website of the Departmen…
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psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
June 28, 2023
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During
Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web…
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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - SPOTLIGHT CASE
Beeline to Spine
Citation Text:
Smetana GW. Beeline to Spine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/actionplan-trip-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Action Plan for Translating Research Into Practice: Gap Analysis and Tests of Change
SAY:
This module will cover the Translating Research Into Practice (TRIP) framework. The TRIP framework lets us dig…
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psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
October 01, 2016 - In Conversation With… Richard Platt, MD, MSc
October 1, 2016
Also Read an Essay
Citation Text:
In Conversation With… Richard Platt, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …