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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - Until then, the approaches described above provide a good starting point to guide medical centers in
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psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
March 01, 2012 - just need somebody I trust who understands my ethics and understands what I want to do and can help guide
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psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
March 01, 2012 - just need somebody I trust who understands my ethics and understands what I want to do and can help guide
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psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
December 01, 2012 - Improving medication administration safety: using naïve observation to assess practice and guide
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psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
June 14, 2023 - SPOTLIGHT CASE
CME/MOC
A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion
Citation Text:
Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.. PSNet [internet]. Rockville (MD): Agency for H…
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psnet.ahrq.gov/node/851568/psn-pdf
July 31, 2023 - A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion
July 31, 2023
Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with
Dexmedetomidine Infusion. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomid…
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - Delay in Appropriate Diagnosis and Treatment Leading to
Death from Pulmonary Embolism
February 10, 2021
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary
Embolism. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leadi…
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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - SPOTLIGHT CASE
Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism
Citation Text:
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - SPOTLIGHT CASE
Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome
Citation Text:
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed Diagnosis with a Severely Negative Outcome. PSNet [internet…
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psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
September 24, 2024 - Second, they guide our path in moment-to-moment decisionmaking—whether in the boardroom, the bedside
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - By identifying clues that guide chart reviewers to specific events during a patient's hospitalization
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psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - By identifying clues that guide chart reviewers to specific events during a patient's hospitalization
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psnet.ahrq.gov/node/73334/psn-pdf
August 01, 2024 - An Inadvertent Bolus of Norepinephrine.
May 26, 2021
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Savitz LA, Sousane Z, Mossburg SE. Learning …
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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Essay
View more articles from the same authors.
Citation Text:
Savitz LA, S…
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psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
December 04, 2016 - SPOTLIGHT CASE
An Inadvertent Bolus of Norepinephrine.
Citation Text:
Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
F…
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - SPOTLIGHT CASE
CME/MOC
The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.
Citation Text:
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Depart…
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx
Spotlight
The Dose Makes the Poison: Medication Error During
Procedural Sedation in the Pediatric Emergency
Department
Source and Credits
• This presentation is based on the April 2023 AH…
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psnet.ahrq.gov/perspective/conversation-elizabeth-salisbury-afshar-about-harm-reduction-strategies-improve-safety
October 30, 2024 - valuable opportunity to identify risky substance use early and utilize long-standing relationships to guide
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psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
October 30, 2024 - valuable opportunity to identify risky substance use early and utilize long-standing relationships to guide