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  1. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event | PSNet

    psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
    July 01, 2017 - SPOTLIGHT CASE “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event Citation Text: Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866261/psn-pdf
    July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery July 10, 2024 Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…

  3. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk | PSNet

    psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
    January 31, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk Citation Text: Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quali…

  4. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. | PSNet

    psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
    March 03, 2021 - SPOTLIGHT CASE Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. Citation Text: Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867359/psn-pdf
    December 18, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk December 18, 2024 Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/importance-following-saf…

  6. In Conversation with…Troyen A. Brennan, MD, JD, MPH | PSNet

    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. …

  7. In Conversation With… Vineet Chopra, MD, MSc | PSNet

    psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
    February 28, 2024 - I recognized that we in hospital medicine were ideally positioned to lead in this space.

  8. In Conversation with…Donald M. Berwick, MD, MPP | PSNet

    psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
    November 01, 2005 - At that point, we did not have the people on board to lead the campaign.

  9. In Conversation With… Nicholas G. Castle, MHA, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
    August 01, 2012 - currently configured does not incentivize substantial financial investment in interventions that might lead

  10. In Conversation with…Pat Croskerry, MD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
    June 01, 2010 - These problems can delay diagnosis and treatment or lead to errors due to breaks in procedural routine

  11. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? | PSNet

    psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
    March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? Ian Scott, MBBS, MHA, MEd | March 1, 2015  Also Read a Conversation View more articles from the same authors. Citation Text: Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety …

  12. Intubation Mishap | PSNet

    psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - SPOTLIGHT CASE Intubation Mishap Citation Text: Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …

  13. In Conversation with...Atul Gawande, MD, MA, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
    September 01, 2007 - In Conversation with...Atul Gawande, MD, MA, MPH September 1, 2007  Also Read an Essay Citation Text: In Conversation with..Atul Gawande, MD, MA, MPH. PSNet [internet]. 2007.In Conversation with...Atul Gawande, MD, MA, MPH. PSNet [internet]. Rockville (MD): Agency…

  14. Health Care Data Science for Quality Improvement and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
    October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety Alvin Rajkomar, MD | October 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Rajkomar A. Health Care Data Science for Quality Improvement and Patient S…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33858/psn-pdf
    May 01, 2018 - In Conversation With… John Halamka, MD, MS May 1, 2018 In Conversation With… John Halamka, MD, MS. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms Editor's note: Dr. Halamka is the International Healthcare Innovation Professor at Harvard Medical School, Chief Information …

  16. Multiple Levels Involved in Prescribing the Wrong Medication | PSNet

    psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
    December 23, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication Citation Text: Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cit…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867035/psn-pdf
    October 30, 2024 - A Tale of Two Falls October 30, 2024 Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/tale-two-falls The Cases Case #1: A 79-year-old woman with a history of impaired cognition at baseline was brought from a skilled nursing facility to the emergency department (ED) f…

  18. Medication Safety in Nursing Homes: What's Wrong and How to Fix It | PSNet

    psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
    August 01, 2012 - currently configured does not incentivize substantial financial investment in interventions that might lead

  19. In Conversation With… Mark Graban, MS, MBA | PSNet

    psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
    January 01, 2015 - organization listens to those people and then helps them fix things, these are the cultural themes that lead

  20. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care | PSNet

    psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
    January 01, 2015 - organization listens to those people and then helps them fix things, these are the cultural themes that lead
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