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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
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Citation Text:
Vogus T, Lee M, Mos…
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psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
May 01, 2019 - Safety in the Prehospital Emergency Medical Services Setting
P. Daniel Patterson, PhD, NRP, and Donald M. Yealy, MD | May 1, 2019
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Citation Text:
Patterson DP, Yealy DM. Safety in the Prehospital…
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psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
August 01, 2015 - In Conversation With… Robert M. Wachter, MD
August 1, 2015
Also Read an Essay
Citation Text:
In Conversation With… Robert M. Wachter, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
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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
Also Read the Essay
View more articles from the same authors.
Ci…
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
July 30, 2020 - Coronavirus Disease 2019 (COVID-19) and Diagnostic Error
Citation Text:
Desai AN, Romano PS. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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psnet.ahrq.gov/node/49693/psn-pdf
October 01, 2013 - It's Sarah, Not Stephen!
October 1, 2013
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/its-sarah-not-stephen
Case Objectives
Define and distinguish the terms gender identity, gender expression, and gender variance.
Delineate patient safety issues associated with transge…
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
April 27, 2022 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?
Citation Text:
Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/web-mm/dressed-failure
September 01, 2011 - DRESSed for Failure
Citation Text:
Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - Pathologic Mistake
Citation Text:
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/hard-swallow
April 26, 2023 - Hard to Swallow
Citation Text:
Driver J. Hard to Swallow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/node/49871/psn-pdf
August 10, 2019 - Renal Failure Due to Benign Prostatic Hyperplasia
August 10, 2019
Barry MJ, Garnick MB. Renal Failure Due to Benign Prostatic Hyperplasia. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
The Case
A 65-year-old man was referred to urology for a 5-year history of …
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psnet.ahrq.gov/node/73650/psn-pdf
August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with
Recurrent Pneumothorax
August 25, 2021
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent
Pneumothorax. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…
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psnet.ahrq.gov/node/841469/psn-pdf
December 14, 2022 - Strongyloides: A Hidden Traveler and Potentially Lethal
Missed Diagnosis.
December 14, 2022
Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed
Diagnosis. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-mi…
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
December 21, 2022 - In Conversation with…Troyen A. Brennan, MD, JD, MPH
December 1, 2005
Citation Text:
In Conversation with…Troyen A. Brennan, MD, JD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
…
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psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - Don't Push
Citation Text:
Meltzer HY. Don't Push. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Downl…
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psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - SPOTLIGHT CASE
Poor Prognosis
Citation Text:
Lamont EB. Poor Prognosis. 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/node/49630/psn-pdf
July 01, 2011 - Watch the Warfarin!
July 1, 2011
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/watch-warfarin
Case Objectives
Understand best practices for safe discharge of patients on warfarin.
Describe recent advances in anticoagulation monitoring for ambulatory patients.
Discu…
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psnet.ahrq.gov/node/49869/psn-pdf
July 02, 2019 - Failure to Rescue the Mother
July 2, 2019
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/failure-rescue-mother
The Case
A 27-year-old woman, G5 P2 A2, was first admitted to the hospital at 25 weeks of pregnancy for vaginal
bleeding. An …