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psnet.ahrq.gov/node/33690/psn-pdf
December 01, 2009 - In Conversation with…Gerald B. Hickson, MD
December 1, 2009
In Conversation with…Gerald B. Hickson, MD . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
Editor's note: Gerald B. Hickson, MD, is one of the world's leading experts on physician behavior and its
connecti…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - Which Line: Ordering Provider or Proceduralist?
March 1, 2019
Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse…
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound
and Patient Safety
July 1, 2018
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
Case Objectives
Unders…
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psnet.ahrq.gov/node/49840/psn-pdf
September 01, 2018 - Steroids and Safety: Preventing Medication Adverse
Events During Transitions of Care
September 1, 2018
Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of
Care. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adver…
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psnet.ahrq.gov/node/49684/psn-pdf
May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical
Error
May 1, 2013
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet].
2013.
https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
Case Objectives
Appreciate that chemotherapy a…
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psnet.ahrq.gov/perspective/communication-during-transitions-care
July 10, 2024 - Annual Perspective
Communication During Transitions of Care
Ayse P. Gurses; Sarah Mossburg; Zoe Sousane
| March 27, 2024
View more articles from the same authors.
Citation Text:
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - SPOTLIGHT CASE
Unexplained Apnea Under Anesthesia
Citation Text:
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX …
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - SPOTLIGHT CASE
Prolonged DKA in Pregnancy: A Case of Communication Breakdown.
Citation Text:
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
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psnet.ahrq.gov/print/pdf/node/866419
March 27, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Artificial Intelligence: System-Level
Considerations
Curated Library
Foundations
Generative artificial intelligence, patient safety and healthcare quality: a review.
Howell MD. BMJ Qual Saf. 2024;33:748-754.
Artificial intelligence (AI) is…
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psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
April 12, 2023 - SPOTLIGHT CASE
Triaging Interhospital Transfers
Citation Text:
Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/866995/psn-pdf
October 30, 2024 - A Cognitive and Communication Blind Spot Contributes
to Permanent Paralysis
October 30, 2024
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
Disclosur…
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psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures
Citation Text:
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
…
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psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - SPOTLIGHT CASE
A "Reflexive" Diagnosis in Primary Care
Citation Text:
Betjemann J, Josephson AS. A "Reflexive" Diagnosis in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
…
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psnet.ahrq.gov/node/33590/psn-pdf
September 15, 2024 - Leadership Role in Improving Safety
September 15, 2024
Leadership Role in Improving Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/leadership-role-improving-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and p…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.2_slideshow.ppt
February 01, 2003 - PowerPoint Presentation
Spotlight Case February 2003
Apnea in a Patient Under General Anesthesia
webmm.ahrq.gov
Source and Credits
This presentation is based on February 2003 Surgery–Anesthesia Spotlight Case
See full case–commentary on webmm.ahrq.gov
CME credit is available online
Commentary by: Paul Barach,…
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psnet.ahrq.gov/node/49790/psn-pdf
April 01, 2017 - Patient Allergies and Electronic Health Records
April 1, 2017
Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
The Case
A 40-year-old woman presented with recurring intense right upper quadrant pain, whi…
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psnet.ahrq.gov/node/867676/psn-pdf
February 26, 2025 - Responding to Patient Safety Events
February 26, 2025
Shaikh U. Responding to Patient Safety Events. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/responding-patient-safety-events
Background
Patient safety events that occur in health care facilities require prompt action to ensure that further harm is
mit…
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psnet.ahrq.gov/node/33613/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—II. The Duke Experience
May 1, 2005
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSNet
[internet]. 2005.
https://psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
Pe…
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psnet.ahrq.gov/primer/communication-between-clinicians
September 15, 2024 - Communication Between Clinicians
Citation Text:
Communication Between Clinicians. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…