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psnet.ahrq.gov/node/49605/psn-pdf
June 01, 2010 - Acute Respiratory Arrest in Pregnancy
June 1, 2010
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
The Case
A 35-year-old woman was 38 weeks pregnant with twins (G3P2). When she developed acute onset of
shortness of breath an…
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psnet.ahrq.gov/node/61079/psn-pdf
October 28, 2020 - When Looks Aren’t All They Appear to Be: A Medication
Error in an Uncommon Indication
October 28, 2020
Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-
…
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - Hold That Order
Citation Text:
Grissinger M. Hold That Order. 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/sites/default/files/import/webmm.ahrq.gov.323_slideshow.ppt
May 01, 2014 - PowerPoint Presentation
Spotlight
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
This presentation is based on the May 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Janice Kwan, MD, Department of Medicine, University of Tor…
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psnet.ahrq.gov/node/33642/psn-pdf
November 01, 2006 - In Conversation With...Donald A. Norman, PhD
November 1, 2006
In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you
become interested…
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - 40 of K
Citation Text:
Lesar TS. 40 of K. 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/web-mm/lost-black-hole
December 01, 2005 - Lost in the Black Hole
Citation Text:
Wachter R. Lost in the Black Hole. 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/web-mm/privacy-gone-awry
February 24, 2011 - Privacy Gone Awry
Citation Text:
Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
April 01, 2015 - Medication Reconciliation Victory After an Avoidable Error
Citation Text:
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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…
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. 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/approach-improving-patient-safety-communication
August 31, 2020 - Annual Perspective
Approach to Improving Patient Safety: Communication
March 10, 2021
View more articles from the same authors.
Citation Text:
Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. Ro…
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psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
June 30, 2021 - In Conversation With... Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA
June 30, 2021
Also Read the Essay
Citation Text:
In Conversation With.. Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA. PSNet [internet]. 2021.In Conversation…
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psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Vogus T, Lee M, Mos…
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psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Ci…
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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - COVID-19 and the Built Environment
June 30, 2021
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Joseph A, Scanlon MM, Fitall E, et al. COVID-19 and the Built Environment. PSNet [internet]. Rockville (MD): Agency for Healthca…
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psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
June 01, 2005 - In response to “Getting to the Root of the Matter” (June 2005)
September 1, 2005
View more articles from the same authors.
Citation Text:
Grondin L, Saint S, Flanders S, et al. In response to “Getting to the Root of the Matter” (June 2005). PSNet [internet]. Rockv…
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psnet.ahrq.gov/node/33591/psn-pdf
March 15, 2025 - Triggers and Trigger Tools
March 15, 2025
Triggers and Trigger Tools. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/triggers-and-trigger-tools
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - Ensuring Patient and Workforce Safety Culture in
Healthcare
March 27, 2024
Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
Introduction
In 2020, the I…
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psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
September 01, 2014 - In Conversation With… Rosemary Gibson, MSc
September 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
September 01, 2007 - In Conversation with...Atul Gawande, MD, MA, MPH
September 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Atul Gawande, MD, MA, MPH. PSNet [internet]. 2007.In Conversation with...Atul Gawande, MD, MA, MPH. PSNet [internet]. Rockville (MD): Agency…