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  1. Psn-Pdf (pdf file)

    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-…
  2. Psn-Pdf (pdf file)

    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…
  3. 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. Copy Citation Format: Google Scholar BibTe…
  4. 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…
  5. 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. Copy Citatio…
  6. 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. Copy Citation Format: Google Scholar Bi…
  7. 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. Copy Citation Format: Google Schol…
  8. 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. Copy Citation Format: …
  9. Spotlight (pdf file)

    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…
  10. 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…
  11. 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. …
  12. Psn-Pdf (pdf file)

    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…
  13. 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. Copy Citation Format: …
  14. 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. Copy Citation Format: …
  15. 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. …
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. 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…

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