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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM
April 1, 2018
In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and
Directo…
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - SPOTLIGHT CASE
One Toxic Drug Is Not Like Another
Citation Text:
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx
Spotlight
Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See…
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH
April 1, 2014
Citation Text:
In Conversation With… Tejal K. Gandhi, MD, MPH. 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/hospital-acquired-diabetic-ketoacidosis
October 28, 2020 - Hospital-Acquired Diabetic Ketoacidosis.
Citation Text:
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis.. 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/postdischarge-follow-phone-call
May 19, 2021 - SPOTLIGHT CASE
Postdischarge Follow-Up Phone Call
Citation Text:
Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Google Schol…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
March 31, 2021 - SPOTLIGHT CASE
Delayed Diagnosis of Mesenteric Ischemia
Citation Text:
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
January 01, 2022 - Spotlight
Spotlight
Perioperative Anaphylaxis After Insertion of
a Latex Drain in a Patient with Known Latex
Allergy
Source and Credits
• This presentation is based on the August 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 K…
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx
Spotlight
Overdose of Gabapentin and Oxycodone in a Patient
with End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts
Source and Credits
• This presentation is based on the January 2023 AHRQ WebM&M
Spotl…
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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. …
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psnet.ahrq.gov/node/846975/psn-pdf
March 28, 2023 - In Conversation with... Christie Allen about Maternal
Safety and Perinatal Mental Health
March 28, 2023
In Conversation with.. Christie Allen about Maternal Safety and Perinatal Mental Health. PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal…
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psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - In Conversation With… Paul McGann, MD
March 1, 2016
Citation Text:
In Conversation With… Paul McGann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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…
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - The Impact of Communication on Medication Errors
Citation Text:
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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…
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement
Carole Stockmeier, Sarah Mossburg, Lee Merton | September 24, 2024
Also Read the Essay
View more articles from the same authors.
…
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psnet.ahrq.gov/node/37146/psn-pdf
August 29, 2007 - Medical error reporting system still a year off.
August 29, 2007
Hansen D.
https://psnet.ahrq.gov/issue/medical-error-reporting-system-still-year
This article reports on the progress of implementing a voluntary system for reporting errors, part of the
Patient Safety and Quality Improvement Act.
https://psnet.ahrq…
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psnet.ahrq.gov/node/39981/psn-pdf
November 03, 2010 - The path to safe and reliable healthcare.
November 3, 2010
Leonard MW, Frankel A. The path to safe and reliable healthcare. Patient Educ Couns. 2010;80(3).
doi:10.1016/j.pec.2010.07.001.
https://psnet.ahrq.gov/issue/path-safe-and-reliable-healthcare
This commentary describes a model that aims to improve health car…
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psnet.ahrq.gov/node/36465/psn-pdf
September 27, 2010 - An interview with Donald Berwick.
September 27, 2010
Berwick DM. An interview with Donald Berwick. Interview by Paul M Schyve. Jt Comm J Qual Patient Saf.
2006;32(12):661-666.
https://psnet.ahrq.gov/issue/interview-donald-berwick
Dr. Berwick, president of the Institute for Healthcare Improvement, discusses his lif…
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psnet.ahrq.gov/node/39167/psn-pdf
February 16, 2011 - Quality and Safety in Medicine.
February 16, 2011
Nash DB, Goldfarb NI, Patow C, eds. Acad Med. 2009;84:1641-1846.
https://psnet.ahrq.gov/issue/quality-and-safety-medicine
This collection of articles highlights efforts to improve quality and safety in academic health centers by
establishing teamwork initiat…
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - Annual Perspective
Diagnostic Errors
Urmimala Sarkar, MD; Kaveh Shojania, MD | January 1, 2014
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. Rockville (MD): Ag…