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  1. Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial. | PSNet

    psnet.ahrq.gov/innovation/pharmacist-led-mobile-health-intervention-and-transplant-medication-safety-randomized
    April 07, 2021 - EMERGING INNOVATIONS Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial. Citation Text: Gonzales HM, Fleming JN, Gebregziabher M, et al. Pharmacist-led mobile health intervention and transplant medication safety: a randomized controll…

  2. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
    January 01, 2021 - discharge, and the PDMP indicates the patient does not have an adequate supply, failure to offer refills leads

  3. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - variety of customizable tools and resources tailored to their specific needs, ensuring that the analysis leads

  4. The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/evolution-root-cause-analysis
    February 26, 2025 - variety of customizable tools and resources tailored to their specific needs, ensuring that the analysis leads

  5. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. | PSNet

    psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
    August 14, 2024 - SPOTLIGHT CASE Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. Citation Text: Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…

  6. In Conversation with...Brent C. James, MD, MStat | PSNet

    psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
    February 26, 2025 - In Conversation with...Brent C. James, MD, MStat February 1, 2011  Citation Text: In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011.In Conversation with...Brent C. James, MD, MStat. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…

  7. Diagnostic Delay in the Emergency Department | PSNet

    psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
    September 18, 2024 - SPOTLIGHT CASE Diagnostic Delay in the Emergency Department Citation Text: Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format:…

  8. Difficult Encounters: A CMO and CNO Respond | PSNet

    psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
    March 01, 2018 - SPOTLIGHT CASE Difficult Encounters: A CMO and CNO Respond Citation Text: Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73153/psn-pdf
    April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough April 28, 2021 Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough Disclosure of Relev…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49682/psn-pdf
    April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case April 1, 2013 Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a Complicated Case. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…

  11. In Conversation With… Maureen Bisognano | PSNet

    psnet.ahrq.gov/perspective/conversation-maureen-bisognano
    February 26, 2025 - In Conversation With… Maureen Bisognano June 1, 2015  Citation Text: In Conversation With… Maureen Bisognano. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73102/psn-pdf
    July 01, 2022 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use March 31, 2021 https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail- community-dwelling Summary Care management staff (such …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867022/psn-pdf
    October 30, 2024 - Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head October 30, 2024 Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-h…

  14. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations | PSNet

    psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
    October 27, 2022 - discharge, and the PDMP indicates the patient does not have an adequate supply, failure to offer refills leads

  15. 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 - April 29, 2020 WebM&M Cases Miscommunication in the OR Leads

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866579/psn-pdf
    August 28, 2024 - Failure to Diagnose and Treat Post- Surgery Infection Leads to $1.18 Million Verdict.

  17. Intubation Mishap | PSNet

    psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - Failure to act on message Distraction leads to delay or failure to give requested drug.

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

    psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
    July 10, 2024 - So, in much the same way that NIH leads the way in basic science research for the country, CMS has now

  19. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care. | PSNet

    psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
    July 08, 2022 - Cases Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60977/psn-pdf
    January 08, 2020 - Medication formularies and prescription patterns vary from facility to facility, which leads to variation
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