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  1. psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
    February 05, 2020 - When oxygen is absent, anaerobic respiration very rapidly leads to lactic acidosis and cardiac arrest
  2. psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
    June 01, 2017 - available.( 1 ) Most of the weekend effect has been attributed to this decreased on-site staffing, which leads
  3. psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
    April 01, 2006 - Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads
  4. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
    January 01, 2024 - Spotlight Spotlight Do Not Miss Sepsis Needles in Viral Haystacks! Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Michelle Hamline, MD, PhD, MAS and Ulfat Shaikh, MD, M…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841566/psn-pdf
    December 14, 2022 - In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety December 14, 2022 In Conversation With.. Dr. Michelle Schreiber on Measuring Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety Editor’s Note: Michelle Schr…
  6. psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
    December 01, 2014 - In Conversation With… Edward Kelley, PhD December 1, 2014  Also Read an Essay Citation Text: In Conversation With… Edward Kelley, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. …
  7. psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
    December 07, 2020 - In Conversation With... Katie J. Suda, PharmD, MS December 7, 2020  Also Read the Essay Citation Text: In Conversation With.. Katie J. Suda, PharmD, MS . PSNet [internet]. 2020.In Conversation With... Katie J. Suda, PharmD, MS . PSNet [internet]. Rockville (MD): …
  8. psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
    November 25, 2020 - SPOTLIGHT CASE Some Patients Can't Wait: Improving Timeliness of Emergency Department Care Citation Text: Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…
  9. psnet.ahrq.gov/issue/enhancing-teamwork-communication-and-patient-safety-responsiveness-paediatric-intensive-care
    March 10, 2021 - Study Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool. Citation Text: Aldawood F, Kazzaz Y, AlShehri A, et al. Enhancing teamwork communication and patient safety responsiveness in a paediatric inte…
  10. psnet.ahrq.gov/issue/what-has-been-impact-covid-19-safety-culture-case-study-large-metropolitan-teaching-hospital
    May 05, 2021 - Study What has been the impact of Covid-19 on safety culture? A case study from a large metropolitan healthcare trust. Citation Text: Denning M, Goh ET, Scott A, et al. What has been the impact of Covid-19 on safety culture? A case study from a large metropolitan healthcare trust. Int J …
  11. psnet.ahrq.gov/issue/safety-manchester-triage-system-detect-critically-ill-children-emergency-department
    October 18, 2023 - Study Safety of the Manchester Triage System to detect critically ill children at the emergency department. Citation Text: Zachariasse JM, Kuiper JW, de Hoog M, et al. Safety of the Manchester Triage System to Detect Critically Ill Children at the Emergency Department. J Pediatr. 2016;17…
  12. psnet.ahrq.gov/issue/electronic-health-record-usability-issues-and-potential-contribution-patient-harm
    July 07, 2021 - Study Classic Electronic health record usability issues and potential contribution to patient harm. Citation Text: Howe JL, Adams KT, Hettinger Z, et al. Electronic Health Record Usability Issues and Potential Contribution to Patient Harm. JAMA. 2018;319(12):127…
  13. psnet.ahrq.gov/issue/association-changing-hospital-readmission-rates-mortality-rates-after-hospital-discharge
    August 20, 2018 - Study Classic Association of changing hospital readmission rates with mortality rates after hospital discharge. Citation Text: Dharmarajan K, Wang Y, Lin Z, et al. Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge. …
  14. psnet.ahrq.gov/issue/diagnostic-errors-intensive-care-unit-systematic-review-autopsy-studies
    March 10, 2021 - Review Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. Citation Text: Winters BD, Custer J, Galvagno SM, et al. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf. 2012;21(11):894-902. doi:10.1136/bmj…
  15. psnet.ahrq.gov/issue/review-alleged-patient-deaths-patient-wait-times-and-scheduling-practices-phoenix-va-health
    May 01, 2015 - Book/Report Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. Citation Text: Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System. Washington, DC: VA Office o…
  16. psnet.ahrq.gov/issue/concordance-urgent-referral-guidelines-patients-presenting-any-six-alarm-features-possible
    February 17, 2021 - Study Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records. Citation Text: Wiering B, Lyratzopoulos G, Hamilton W, et al. Concordance with urgent referral gui…
  17. psnet.ahrq.gov/issue/relationship-between-state-malpractice-environment-and-quality-health-care-united-states
    June 21, 2017 - Study Relationship between state malpractice environment and quality of health care in the United States. Citation Text: Bilimoria KY, Chung JW, Minami CA, et al. Relationship Between State Malpractice Environment and Quality of Health Care in the United States. Jt Comm J Qual Patient Sa…
  18. psnet.ahrq.gov/issue/physician-intent-pharmacy-label-prevalence-and-description-discrepancies-cross-sectional
    July 22, 2020 - Study From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions. Citation Text: Cochran GL, Klepser DG, Morien M, et al. From physician intent to the pharmacy label: prevalence and description o…
  19. psnet.ahrq.gov/issue/national-cost-adverse-drug-events-resulting-inappropriate-medication-related-alert-overrides
    July 02, 2019 - Study The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States. Citation Text: Slight SP, Seger DL, Franz C, et al. The national cost of adverse drug events resulting from inappropriate medication-related alert override…
  20. psnet.ahrq.gov/issue/association-2011-acgme-resident-duty-hour-reform-general-surgery-patient-outcomes-and
    September 09, 2015 - Study Classic Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance. Citation Text: Rajaram R, Chung JW, Jones AT, et al. Association of the 2011 ACGME resident duty hour reform wi…

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