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psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md
June 01, 2018 - In Conversation With… Richard Hoppmann, MD 
 June 1, 2018 
                       
 
 
 
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 Citation Text: 
 In Conversation With… Richard Hoppmann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. 
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - SPOTLIGHT CASE
         
 The Risks of a Malpositioned Gastrostomy Tube and Poor Communication 
 
 
 
 
 Citation Text: 
 Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic… 
                                     
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS  
 August 1, 2009 
                       
 
 
 
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 Citation Text: 
 In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.In Conversation with...Steven J. Spear, DBA, MS, MS . PSNet [internet]. Rockville (MD… 
                                     
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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/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  
 
 
 
 
 
 
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 Citation Text: 
 Vogus T, Lee M, Mos… 
                                     
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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things Changed? 
 Helen Haskell, MA | June 1, 2014 
                       
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 Citation Text: 
 Haskell H. Patient Advocacy in Patient Safety: Have Things Changed?. PSNet [internet]. Ro… 
                                     
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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/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… 
                                     
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psnet.ahrq.gov/web-mm/missed-pneumonia
June 01, 2005 - Missed Pneumonia 
 
 
 
 
 Citation Text: 
 Rohde JM, Flanders S. Missed Pneumonia. 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/33717/psn-pdf
September 01, 2011 - Incident Reporting: More Attention to the Safety Action
Feedback Loop, Please
September 1, 2011
Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet
[internet]. 2011.
https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm 
CME credit is available 
Commentary … 
                                     
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psnet.ahrq.gov/web-mm/poorly-advanced-directives
August 01, 2018 - Poorly Advanced Directives 
 
 
 
 
 Citation Text: 
 Anderson WG. Poorly Advanced Directives. 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/web-mm/no-bp-during-nibp
March 01, 2011 - No BP During NIBP 
 
 
 
 
 Citation Text: 
 Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. 
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psnet.ahrq.gov/node/865984/psn-pdf
May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain
with Elevated D-dimer.
May 29, 2024
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-
dimer. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d… 
                                     
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - Discontinued Medications: Are They Really Discontinued? 
 
 
 
 
 Citation Text: 
 Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. 
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psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
October 01, 2017 - Preventing PICC Complications: Whose Line Is It? 
 
 
 
 
 Citation Text: 
 Moureau N. Preventing PICC Complications: Whose Line Is It?. 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/72618/psn-pdf
December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral
Changes Towards Medical Decisions that Improve Care
Value and Quality of Care
December 23, 2020
https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-
medical-decisions
Summary
Nudges are a change in the way choices ar… 
                                     
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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error 
 
 
 
 
 Citation Text: 
 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. 
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Patient Identification Errors: A Systems Challenge 
 
 
 
 
 Citation Text: 
 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. 
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 Googl… 
                                     
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psnet.ahrq.gov/node/49677/psn-pdf
February 01, 2013 - CVC Placement: Speak Now or Do Not Use the Line
February 1, 2013
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
The Case
A 48-year-old woman with a history of hypertension, psychiatric illness, and a…