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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…
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psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
August 01, 2017 - The Evolution of Patient Safety in Surgery
Robert M. Wachter, MD | December 1, 2017
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Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
May 26, 2021 - Endometriosis: A Common and Commonly Missed and Delayed Diagnosis
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Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up
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Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. 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/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
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Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Hea…
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - In Conversation With... David Gruen, MD
January 31, 2020
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In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.In Conversation With... David Gruen, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research an…
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
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In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - Complications of ECMO During Transport
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Broman M. Complications of ECMO During Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - SPOTLIGHT CASE
Diagnosing HIV-It Doesn't Take a Brain Surgeon
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Chou R. Diagnosing HIV-It Doesn't Take a Brain Surgeon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
June 01, 2011 - In Conversation with… Edward Tenner, PhD
June 1, 2011
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In Conversation with… Edward Tenner, PhD. 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/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
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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.
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD
June 1, 2005
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In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD (hon)
April 1, 2006
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In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
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psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
November 01, 2017 - In Conversation With… Wanda Pratt, PhD
November 1, 2017
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In Conversation With… Wanda Pratt, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/innovation/critical-radiology-alert-process
November 16, 2022 - Critical Radiology Alert Process
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October 30, 2024
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psnet.ahrq.gov/web-mm/little-shuteye
December 22, 2018 - A Little Shuteye
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Farion KJ. A Little Shuteye. 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/node/849660/psn-pdf
May 31, 2023 - Strategies to Improve Organizational Health Literacy.
May 31, 2023
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
Background
Health literacy is important at both the personal …
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
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psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety
Sara J. Singer, MBA, PhD | September 1, 2013
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Singer SJ. What We've Learned About Leveraging Leadership a…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
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Conway JB, Weingart SN. Organizational Change…