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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near- Miss Wrong Transfusion Event January 29, 2020 Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…

  2. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure | PSNet

    psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
    March 01, 2005 - SPOTLIGHT CASE CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure Citation Text: Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838900/psn-pdf
    October 27, 2022 - Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. October 27, 2022 Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/fecal-contamination-…

  4. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-10/trocar_injury_final.pdf
    January 01, 2022 - Spotlight Spotlight Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong Source and Credits • This presentation is based on the October 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33776/psn-pdf
    January 01, 2015 - In Conversation With… Mark Graban, MS, MBA January 1, 2015 In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba Editor's note: Mark Graban, MS, MBA, is an internationally recognized expert in Lean Healthcare, which has become one of…

  6. In Conversation With… Tejal K. Gandhi, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
    February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH April 1, 2014  Citation Text: In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citatio…

  7. A Sweet Case of Hidden Hydrogen Ions | PSNet

    psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
    November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions Citation Text: Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  8. Patient and Family Roles in Safety | PSNet

    psnet.ahrq.gov/perspective/patient-and-family-roles-safety
    June 14, 2023 - Patient and Family Roles in Safety Beverley H. Johnson, FAAN, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD | June 14, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Johnson B, Lee M, Mossburg S. Patient and Fam…

  9. In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm | PSNet

    psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
    June 14, 2023 - In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm Beverley H. Johnson, FAAN | June 14, 2023  Also Read the Essay View more articles from the same authors. Citation Text: Johnson B. In Conversation with.. Beverley H…

  10. In Conversation With… Mary Dixon-Woods, DPhil | PSNet

    psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
    March 01, 2017 - In Conversation With… Mary Dixon-Woods, DPhil March 1, 2017  Also Read an Essay Citation Text: In Conversation With… Mary Dixon-Woods, DPhil. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  11. The Role of the FDA in Ensuring Device Safety | PSNet

    psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
    May 28, 2020 - The Role of the FDA in Ensuring Device Safety May 28, 2020  Also Read the Conversation View more articles from the same authors. Citation Text: Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. Rockville (MD): Agency f…

  12. What Happened on Telemetry? | PSNet

    psnet.ahrq.gov/web-mm/what-happened-telemetry
    January 18, 2012 - SPOTLIGHT CASE What Happened on Telemetry? Citation Text: Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNo…

  13. In Conversation With… Mark Chassin, MD, MPP, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
    April 26, 2023 - In Conversation With… Mark Chassin, MD, MPP, MPH April 1, 2017  Citation Text: In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Cit…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867805/psn-pdf
    February 26, 2025 - In Conversation with David W. Bates about Are We Safer Today? February 26, 2025 Bates DW, Lee M, Mossburg SE. In Conversation with David W. Bates about Are We Safer Today? PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today Editor’s note: David W. Bates, …

  15. 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…

  16. 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…

  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/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…

  19. In Conversation with…Christopher P. Landrigan, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
    April 01, 2005 - In Conversation with…Christopher P. Landrigan, MD April 1, 2005  Also Read an Essay Citation Text: In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867653/psn-pdf
    February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evoluti…
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