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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49801/psn-pdf
    August 01, 2017 - Despite Clues, Failed to Rescue August 1, 2017 Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue Case Objectives Define failure to rescue. Identify the main contributors to failure-to-rescue events. Appreciate the ongoing areas of scien…
  2. psnet.ahrq.gov/web-mm/forgotten-turn
    August 01, 2018 - SPOTLIGHT CASE The Forgotten Turn Citation Text: Barbour S. The Forgotten Turn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
  3. psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
    August 21, 2024 - SPOTLIGHT CASE Don't Dismiss the Dangerous: Obstetric Hemorrhage Citation Text: Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …
  4. psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
    January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx Spotlight A Loss of Trust and a Missed Diagnosis Source and Credits • This presentation is based on the February 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near- Miss Wrong Transfusion Event January 29, 2020 Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74121/psn-pdf
    November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. November 30, 2021 Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…
  7. psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
    January 31, 2024 - In Conversation With… John D. Birkmeyer, MD May 1, 2015  Citation Text: In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Fo…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33688/psn-pdf
    October 01, 2009 - In Conversation with... Charles Ornstein October 1, 2009 In Conversation with.. Charles Ornstein . PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-charles-ornstein Editor's note: Charles Ornstein is a senior reporter at ProPublica, a nonprofit news organization in New York. Formerly with th…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33878/psn-pdf
    April 01, 2019 - In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD April 1, 2019 In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd Editor's note: Dr. Schulz Moore is the Director of Learning and Teaching at…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33867/psn-pdf
    October 01, 2018 - In Conversation With… Michael Cohen, RPh, MS, ScD (hon) October 1, 2018 In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0 Editor's note: Dr. Cohen is President of the Institute for Safe Medication Practice…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33759/psn-pdf
    October 01, 2012 - Promising Areas for Patient Safety Research December 1, 2003 Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. PSNet [internet]. 2003. https://psnet.ahrq.gov/perspective/promising-areas-patient-safety-research Perspective Setting a Course for Patient Safety Research Although patient safety…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49525/psn-pdf
    December 01, 2006 - Hidden Heparins: HIT Happens December 1, 2006 Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens Case Objectives Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication, thrombosis. Discuss the managem…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33686/psn-pdf
    August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS August 1, 2009 In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms Editor's note: Steven Spear, DBA, MS, MS, is Senior Lecturer at Massachusetts Institute of Tech…
  14. psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
    July 21, 2020 - SPOTLIGHT CASE Anemia and Delayed Colon Cancer Diagnosis Citation Text: Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33776/psn-pdf
    January 01, 2015 - In Conversation With… Mark Graban, MS, MBA January 1, 2015 In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba Editor's note: Mark Graban, MS, MBA, is an internationally recognized expert in Lean Healthcare, which has become one of…
  16. psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
    August 31, 2022 - SPOTLIGHT CASE Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. Citation Text: Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  17. psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
    January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO January 12, 2022  Also Read the Essay Citation Text: In Conversation With.…
  18. psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
    January 12, 2022 - Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic January 12, 2022  Also Read the Conversation View more articles from the same authors. Citation Text: Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and…
  19. psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
    September 28, 2022 - In Conversation With... Jack Westfall, MD, MPH September 28, 2022  Also Read the Essay Citation Text: In Conversation With.. Jack Westfall, MD, MPH. PSNet [internet]. 2022.In Conversation With... Jack Westfall, MD, MPH. PSNet [internet]. Rockville (MD): Agency for…
  20. psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
    August 01, 2019 - What's the business case to say it's worth $2 million of institutional money because of these results

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