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AHRQ: Agency for Healthcare Research and Quality

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  1. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet

    psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
    January 29, 2021 - An Incomplete Anesthesia History Leads to Adverse Outcomes Citation Text: Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …

  2. Anemia and Delayed Colon Cancer Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
    July 21, 2020 - SPOTLIGHT CASE Anemia and Delayed Colon Cancer Diagnosis Citation Text: Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848107/psn-pdf
    April 26, 2023 - Improving Diagnostic Safety and Quality April 26, 2023 Al-Khafaji J, Lee M, Mossburg S. Improving Diagnostic Safety and Quality . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality Introduction During an annual editorial review of featured articles in the Agency for …

  4. The Perils of Cross Coverage | PSNet

    psnet.ahrq.gov/web-mm/perils-cross-coverage
    September 22, 2010 - SPOTLIGHT CASE The Perils of Cross Coverage Citation Text: Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX En…

  5. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet

    psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
    May 01, 2018 - SPOTLIGHT CASE Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency Citation Text: Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

  6. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis | PSNet

    psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
    January 13, 2010 - SPOTLIGHT CASE A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis Citation Text: Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…

  7. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet

    psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
    October 01, 2004 - SPOTLIGHT CASE Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Citation Text: Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33787/psn-pdf
    January 01, 2018 - In Conversation With… Maureen Bisognano June 1, 2015 In Conversation With… Maureen Bisognano. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-maureen-bisognano Editor's note: Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement (IHI). We spoke with her about I…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49717/psn-pdf
    September 01, 2014 - A Lot of Pain (Medications) September 1, 2014 Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/lot-pain-medications Case Objectives Appreciate the challenges of managing acute pain in hospitalized patients on chronic opioids. Describe the importance of understanding th…

  10. Improving Diagnostic Safety and Quality | PSNet

    psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
    February 22, 2023 - Annual Perspective Improving Diagnostic Safety and Quality Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD | April 26, 2023  View more articles from the same authors. Citation Text: Al-Khafaji J, Lee M, Mossburg S. Improving Di…

  11. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet

    psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
    September 30, 2020 - SPOTLIGHT CASE Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Citation Text: Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33759/psn-pdf
    October 01, 2012 - Promising Areas for Patient Safety Research December 1, 2003 Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. PSNet [internet]. 2003. https://psnet.ahrq.gov/perspective/promising-areas-patient-safety-research Perspective Setting a Course for Patient Safety Research Although patient safety…

  13. In Conversation With… Paul Aylin, MBChB | PSNet

    psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
    June 01, 2017 - In Conversation With… Paul Aylin, MBChB June 1, 2017  Also Read an Essay Citation Text: In Conversation With… Paul Aylin, MBChB. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50698/psn-pdf
    November 27, 2019 - Missed Opportunities for Suicide Risk Assessment November 27, 2019 Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…

  15. 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…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33752/psn-pdf
    August 01, 2013 - In Conversation With… J. Bryan Sexton, PhD, MA August 1, 2013 In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma Editor's note: J. Bryan Sexton, PhD, is associate professor and director of the Patient Safety Center for the D…

  17. Microsoft PowerPoint - Spotlight Case_Hindsight is 2020_SLIDES_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_hindsight_is_2020_slides_final.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Hindsight is 2020_SLIDES_FINAL.pptx Spotlight Hindsight is 20/20: Thrombolytics for Alcohol Intoxication Source and Credits • This presentation is based on the April 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is avail…

  18. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-04/final_april-spotlight-implicit_biases_04.02.2020.pdf
    January 01, 2020 - Spotlight Spotlight Implicit Biases, Interprofessional Communication, and Power Dynamics Source and Credits • This presentation is based on the April 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Erin Stephany Sanchez, MD, Melody Tran- Reina, MD, Kupi…

  19. In Conversation With… J. Bryan Sexton, PhD, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
    February 26, 2025 - In Conversation With… J. Bryan Sexton, PhD, MA August 1, 2013  Citation Text: In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citati…

  20. 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: …
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