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  1. Ensuring Patient and Workforce Safety Culture in Healthcare | PSNet

    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…

  2. Psn-Pdf (pdf file)

    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…

  3. Hypoxic Gas Supply from Cross-Connected Pipelines | PSNet

    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. Copy Citation Format: Google S…

  4. 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…

  5. Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. | PSNet

    psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
    August 14, 2024 - SPOTLIGHT CASE Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. Citation Text: Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850673/psn-pdf
    June 14, 2023 - I asked, “is the momentum so great now that family-centered care will just happen, and we can go away

  7. In Conversation with…Sanjay Saint, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
    November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH November 1, 2008  Also Read an Essay Citation Text: In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 200…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49720/psn-pdf
    December 01, 2014 - A Stroke of Error December 1, 2014 Barrett KM. A Stroke of Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/stroke-error Case Objectives State the key clinical factors to assess in a patient with suspected stroke. Appreciate the relationship between elevated blood pressure and stroke in the acute sett…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865454/psn-pdf
    March 27, 2024 - Ensuring Patient and Workforce Safety Culture in Healthcare March 27, 2024 Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare Introduction In 2020, the I…

  10. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions | PSNet

    psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
    November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions Lindsay E. Nicolle, MD | November 1, 2008  Also Read a Conversation View more articles from the same authors. Citation Text: Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Pr…

  11. In Conversation with…Janet Corrigan, PhD, MBA | PSNet

    psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
    April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010  Also Read an Essay Citation Text: In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  12. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

  13. In Conversation With... Anna Legreid Dopp, Pharm. D | PSNet

    psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
    June 29, 2020 - In Conversation With... Anna Legreid Dopp, Pharm. D June 29, 2020  Also Read the Essay Citation Text: In Conversation With.. Anna Legreid Dopp, Pharm. D. PSNet [internet]. 2020.In Conversation With... Anna Legreid Dopp, Pharm. D. PSNet [internet]. Rockville (MD): …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848110/psn-pdf
    April 26, 2023 - Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. April 26, 2023 Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes Disclosure of Relevant Financial R…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852700/psn-pdf
    August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety August 30, 2023 McGaffigan P, Van CM, Mossburg S. In Conversation with.. Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/con…

  16. WebM&M: Case Studies | PSNet

    psnet.ahrq.gov/webmm-case-studies
    March 25, 2025 - WebM&M: Case Studies WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…

  17. Retained Surgical Items: Causation and Prevention | PSNet

    psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
    January 04, 2024 - Retained Surgical Items: Causation and Prevention Citation Text: Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX End…

  18. In Conversation with…Eric G. Poon, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
    September 01, 2008 - RW: Given that such a high percentage of errors in the medication process happen at a point that begins

  19. In Conversation With… Gregg S. Meyer, MD, MSc | PSNet

    psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
    June 01, 2016 - When I think back to my days at AHRQ, we had a fantasy that something like this would begin to happen

  20. The Role of Bar Coding and Smart Pumps in Safety | PSNet

    psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
    September 01, 2008 - RW: Given that such a high percentage of errors in the medication process happen at a point that begins
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