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psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
November 04, 2015 - Patient Safety in the Physician Office Setting
Nancy C. Elder, MD, MSPH | May 1, 2006
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Citation Text:
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/web-mm/feeling-no-pain
August 30, 2023 - Feeling No Pain
Citation Text:
Bogner MS. Feeling No Pain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
November 03, 2015 - Health Care Worker Presenteeism: A Challenge for Patient Safety
Julia E. Szymczak, PhD | October 1, 2017
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Citation Text:
Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. Rockvi…
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psnet.ahrq.gov/web-mm/turn-other-cheek
October 26, 2010 - Turn the Other Cheek
Citation Text:
Starling J. Turn the Other Cheek. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Check the Anesthesia Machine
Citation Text:
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. 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/perspective/rethinking-root-cause-analysis
August 21, 2016 - Annual Perspective
Rethinking Root Cause Analysis
Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016
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Citation Text:
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering
Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019
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Citation Text:
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…
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psnet.ahrq.gov/periodic-issue/periodic-issue-472
February 26, 2025 - February 26, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, repor…
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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D…
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psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
February 17, 2021 - Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls
Citation Text:
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departme…
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psnet.ahrq.gov/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room
Citation Text:
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…
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psnet.ahrq.gov/node/33845/psn-pdf
November 01, 2017 - In Conversation With… Wanda Pratt, PhD
November 1, 2017
In Conversation With… Wanda Pratt, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
Editor's note: Wanda Pratt is a Professor in the Information School with an adjunct appointment in the
Division of Biomedical and …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
July 01, 2012 - Spotlight Case July 2008
Spotlight Case
Not-So-Therapeutic Tap
*
*
Source and Credits
This presentation is based on the July 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeffrey H. Barsuk, MD, MS; Northwestern University Feinberg Scho…
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psnet.ahrq.gov/node/33646/psn-pdf
February 01, 2007 - In Conversation with...Joseph Britto, MD
February 1, 2007
In Conversation with..Joseph Britto, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
Editor's Note: Joseph Britto, MD, is CEO and Co-founder of Isabel Healthcare Inc. Isabel, a clinical
decision support syste…
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Danger in Disruption
October 1, 2009
Fontaine DK. Danger in Disruption. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had
metabolic alkalosis (pH = 7.58), and her last peripheral…
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psnet.ahrq.gov/node/49607/psn-pdf
August 01, 2010 - Missed Patient Assignment: Is Anyone There?
August 1, 2010
Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
The Case
In one hospital, nurses' patient assignments were communicated by listing the…
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psnet.ahrq.gov/web-mm/collegiality-vs-competence
August 28, 2024 - Collegiality vs. Competence
Citation Text:
Sagin T. Collegiality vs. Competence. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/50859/psn-pdf
January 31, 2020 - In Conversation With... David Gruen, MD
January 31, 2020
In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-david-gruen-md
Editor’s note: David R. Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson
Health and is a thought leader and…
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psnet.ahrq.gov/node/49673/psn-pdf
December 01, 2012 - A Real Heartache
December 1, 2012
Polevoi SK. A Real Heartache. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/real-heartache
The Case
A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The
pain began at rest, and it radiated to his back and left axilla. He had…
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psnet.ahrq.gov/node/33661/psn-pdf
December 01, 2007 - Care Transitions
December 1, 2007
Kripalani S. Care Transitions. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/care-transitions
Perspective
Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients
pack their belongings and return home. Physicians scratch …