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  1. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation? | PSNet

    psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
    September 01, 2006 - that keeping patients healthy by providing preventive services and better disease management would lead

  2. The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance | PSNet

    psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
    April 01, 2010 - RW: You have a unique perspective on all of this having been at and helped lead the IOM reports on safety

  3. Interpreting the Patient Safety Literature | PSNet

    psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
    June 01, 2005 - At the time, there was no program for someone to learn how to lead quality and safety efforts, because

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73398/psn-pdf
    June 30, 2021 - In Conversation With... Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA June 30, 2021 In Conversation With.. Anjali Joseph, PhD, EDAC and Molly M. Scanlon, PhD, FAIA, FACHA. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia- …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60977/psn-pdf
    January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong Medication September 30, 2020 Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication The Case A 65-year-old woman co…

  6. In Conversation With… Vineet Arora, MD, MAPP | PSNet

    psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
    May 31, 2023 - In Conversation With… Vineet Arora, MD, MAPP September 1, 2015  Citation Text: In Conversation With… Vineet Arora, MD, MAPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citatio…

  7. 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…

  8. Beeline to Spine | PSNet

    psnet.ahrq.gov/web-mm/beeline-spine
    March 01, 2014 - SPOTLIGHT CASE Beeline to Spine Citation Text: Smetana GW. Beeline to Spine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

  9. In Conversation With… Paul McGann, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
    July 10, 2024 - In Conversation With… Paul McGann, MD March 1, 2016  Citation Text: In Conversation With… Paul McGann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …

  10. Unseen Perils of Urinary Catheters | PSNet

    psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
    January 31, 2024 - Unseen Perils of Urinary Catheters Citation Text: Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar Bib…

  11. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
    January 01, 2022 - Spotlight Spotlight A Case of Mistaken Capacity: Why a Thorough Psychosocial History Can Improve Care Source and Credits • This presentation is based on the March 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Katrina Pasao, MD…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836794/psn-pdf
    March 31, 2022 - A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. March 31, 2022 Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-c…

  13. Dying in the Hospital With Advanced Dementia | PSNet

    psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
    November 01, 2016 - SPOTLIGHT CASE Dying in the Hospital With Advanced Dementia Citation Text: Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Ci…

  14. Pitfalls in Diagnosing Necrotizing Fasciitis | PSNet

    psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
    March 24, 2021 - SPOTLIGHT CASE Pitfalls in Diagnosing Necrotizing Fasciitis Citation Text: Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …

  15. 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…

  16. 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…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49759/psn-pdf
    May 01, 2016 - Falling Through the Crack (in the Bedrails) May 1, 2016 Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/falling-through-crack-bedrails Case Objectives Review the epidemiology of patient falls and associated injuries in the hospital set…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49714/psn-pdf
    August 21, 2014 - Pitfalls in Diagnosing Necrotizing Fasciitis August 21, 2014 Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis Case Objectives State the epidemiology of necrotizing fasciitis. Appreciate the high mortality a…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49415/psn-pdf
    September 01, 2003 - Intubation Mishap September 1, 2003 Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/intubation-mishap Case Objectives To understand and apply a structured method of human factors case analysis To describe the key components of effective teamwork To understand the imp…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33804/psn-pdf
    March 03, 2016 - In Conversation With… Paul McGann, MD March 1, 2016 In Conversation With… Paul McGann, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for Medicare & Medicaid Services (CMS). He…
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