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psnet.ahrq.gov/Information/Editor
May 23, 2025 - Browse Author Resources
Meet PSNet's Editorial Team The PSNet editorial team is committed to producing the highest quality patient safety content. The team brings a wealth of experience and deep subject matter expertise in the field, ensuring that PSNet content is accurate, reliable, and…
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psnet.ahrq.gov/curated-library/organizational-learning
October 27, 2025 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
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June 12, 2020
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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…
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psnet.ahrq.gov/node/33732/psn-pdf
July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP
July 1, 2012
In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
Editor's note: David Blumenthal, MD, MPP, is Chief Health Information and Innovation Officer, Partners
Healt…
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psnet.ahrq.gov/node/33784/psn-pdf
April 01, 2015 - In Conversation With… David Urbach, MD, MSc
April 1, 2015
In Conversation With… David Urbach, MD, MSc. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
Editor's note: Dr. David Urbach is Professor of Surgery and Health Policy, Management, and Evaluation
at the University…
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - SPOTLIGHT CASE
The Safety and Quality of Long Term Care
Citation Text:
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - SPOTLIGHT CASE
False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.
Citation Text:
Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
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psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care
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May 26, 2021
Innovation
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-occult-hemothorax-following-complicated-central-line
April 01, 2008 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest
Citation Text:
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. Rockvil…
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psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - SPOTLIGHT CASE
Impatient Inpatient Dosing
Citation Text:
White RH. Impatient Inpatient Dosing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Google Scholar BibTeX EndNote X3 XML E…
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.
Citation Text:
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - SPOTLIGHT CASE
Physical Diagnosis: A Lost Art?
Citation Text:
Thompson GR, Verghese A. Physical Diagnosis: A Lost Art?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/60790/psn-pdf
February 23, 2022 - COVID-19 and Dentistry: Challenges and Opportunities
for Providing Safe Care
February 23, 2022
Kalenderian E, Spallek H, Franklin A, et al. COVID-19 and Dentistry: Challenges and Opportunities for
Providing Safe Care. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-oppor…
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - Spotlight
Spotlight
Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head
1
Source and Credits
This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Ryan Martin, MD, FCNS and …
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psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.
Citation Text:
Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.. PSNet [internet]. Rockville (MD): Agency for He…
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - SPOTLIGHT CASE
The Wet Read
Citation Text:
Arenson RL. The Wet Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/node/60329/psn-pdf
May 14, 2020 - In Conversation With... Joel Willis, DO, PA, MA, MPhiL
and Neal Sikka, MD
May 14, 2020
In Conversation With.. Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
Editor’s note: Joel Willis, DO, PA, M…
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psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - SPOTLIGHT CASE
"The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety
Citation Text:
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/web-mm/translating-normal-abnormal
October 02, 2019 - SPOTLIGHT CASE
Translating From Normal to Abnormal
Citation Text:
Turner AM. Translating From Normal to Abnormal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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