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  1. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
    June 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfer Troubles 1 2 Source and Credits This presentation is based on the June 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33656/psn-pdf
    September 01, 2007 - In Conversation with...Atul Gawande, MD, MA, MPH September 1, 2007 In Conversation with..Atul Gawande, MD, MA, MPH. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph Editor's Note: Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School a…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49497/psn-pdf
    December 01, 2005 - Slippery Slide Into Life December 1, 2005 Halamek LP. Slippery Slide Into Life. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/slippery-slide-life The Case A 25-year-old woman presented to the hospital in labor and at full gestation after receiving uncomplicated prenatal care. A third-year obstetrics and g…
  4. psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
    February 26, 2025 - In Conversation with...Diane Rydrych, MA June 1, 2007  Citation Text: In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.In Conversation with...Diane Rydrych, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department…
  5. psnet.ahrq.gov/web-mm/wrong-channel
    February 01, 2003 - The Wrong Channel Citation Text: Gosbee JW. The Wrong Channel . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
  6. psnet.ahrq.gov/web-mm/missing-suction-tip
    January 01, 2006 - SPOTLIGHT CASE The Missing Suction Tip Citation Text: Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33622/psn-pdf
    November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP November 1, 2005 In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare I…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60376/psn-pdf
    July 30, 2020 - COVID-19: Team and Human Factors to Improve Safety July 30, 2020 Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety Background The rapid transmission of COVID-19 has resulted in an international pandem…
  9. psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
    January 31, 2020 - Annual Perspective Updates in the Role of Health IT in Patient Safety February 21, 2020  View more articles from the same authors. Citation Text: Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. Rockville …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836839/psn-pdf
    March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare Staff March 31, 2022 Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff Introduction The…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33769/psn-pdf
    June 01, 2014 - Patient Advocacy in Patient Safety: Have Things Changed? June 1, 2014 Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed Perspective In 1981, a cancer patient named Paula Carroll founded…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50928/psn-pdf
    February 21, 2020 - Updates in the Role of Health IT in Patient Safety February 21, 2020 Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety Background Health information technology (HIT) has the potential…
  13. psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
    November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line Citation Text: Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar …
  14. psnet.ahrq.gov/web-mm/too-tight-control
    March 20, 2013 - SPOTLIGHT CASE Too Tight Control Citation Text: Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33678/psn-pdf
    January 01, 2009 - In Conversation with…Thomas H. Gallagher, MD January 1, 2009 In Conversation with…Thomas H. Gallagher, MD. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md Editor's note: Thomas H. Gallagher, MD, is Associate Professor in the Department of Medicine and the Departme…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33729/psn-pdf
    May 01, 2012 - The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety May 1, 2012 Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33841/psn-pdf
    September 01, 2017 - In Conversation With… Andrew Gettinger, MD September 1, 2017 In Conversation With… Andrew Gettinger, MD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md Editor's note: Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the Office of Cli…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33746/psn-pdf
    March 01, 2013 - In Conversation With… David M. Gaba, MD March 1, 2013 In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of Medicine. An international leade…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49654/psn-pdf
    June 01, 2012 - Transfer Troubles June 1, 2012 Hains IM. Transfer Troubles. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients between hospitals is common. Understand the frequency of errors and adverse events in the transfer of patients between hospitals. …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33707/psn-pdf
    February 01, 2011 - The University of Texas System Clinical Safety and Effectiveness Course February 1, 2011 Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and Effectiveness Course. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…

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