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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
June 28, 2023
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue
Necrosis and Cuff Rupture. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
November 13, 2024 - Delayed Diagnosis of Endocrinologic Emergencies
Citation Text:
Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - In Conversation With… Christopher P. Landrigan, MD,
MPH
April 1, 2013
In Conversation With… Christopher P. Landrigan, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
Editor's note: Christopher P. Landrigan, MD, is Associate Professor of Medicine and …
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psnet.ahrq.gov/node/49723/psn-pdf
January 01, 2015 - Monitoring Fetal Health
January 1, 2015
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/monitoring-fetal-health
Case Objectives
Define fetal heart rate monitoring.
Describe the current state of evidence regarding fetal heart rate monitoring.
List the known …
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psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
May 04, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Diagnostic Safety Improvement
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNe…
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - Breadcrumb
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Maternal Safety
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - SPOTLIGHT CASE
The Perils of Cross Coverage
Citation Text:
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/837959/psn-pdf
August 31, 2022 - Perioperative Anaphylaxis After Insertion of a Latex Drain
in a Patient with Known Latex Allergy
August 31, 2022
Kelly KJ. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertio…
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psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
March 01, 2009 - In Conversation with...Dean Schillinger, MD
March 22, 2009
Also Read an Essay
Citation Text:
In Conversation with..Dean Schillinger, MD. PSNet [internet]. 2009.In Conversation with...Dean Schillinger, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - Warning System based on networked bedside monitors could have triggered an early, automated call to the institutional
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - thinking skills, the ability to identify high-risk presentations, clinical experience and expertise, and institutional
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - successful implementation and results, the
innovator recognized value in the ASN innovation and subsequent institutional
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psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Medicaid Expenditures: Growth in Medicaid expenditures for SASH participants over 65 in
institutional
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Medication reviews can potentially reduce these risks, but they tend to occur primarily in
institutional
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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Medicaid Expenditures: Growth in Medicaid expenditures for SASH participants over 65 in institutional
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psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - A multi-institutional international study of risk factors for hematoma after thyroidectomy.
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - Conferences
(5)
Root Cause Analysis
(27)
Error Reporting
(30)
Institutional
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - successful implementation and results, the innovator recognized value in the ASN innovation and subsequent institutional
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - Spotlight
Spotlight
Lost in Transitions of Care: Managing an
Opioid-Dependent Patient with Frequent
Hospitalizations
Source and Credits
• This presentation is based on the September 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary …
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psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
September 01, 2017 - Assessing the Safety of Electronic Health Records: What Have We Learned?
Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH | September 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Sittig DF, Singh H. Assessing the Safe…