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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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 …
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. 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…
  8. 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. Copy Citation Format: Google Scholar BibTeX …
  9. 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…
  10. 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…
  11. 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…
  12. Psn-Pdf (pdf file)

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

    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…
  16. 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,…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

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