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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72517/psn-pdf
    November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. November 25, 2020 Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…

  2. Promising Areas for Patient Safety Research | PSNet

    psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
    November 02, 2016 - Promising Areas for Patient Safety Research P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH | December 1, 2003  View more articles from the same authors. Citation Text: Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. …

  3. Equity in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/equity-patient-safety
    September 24, 2024 - Annual Perspective Equity in Patient Safety Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD | March 27, 2024  View more articles from the same authors. Citation Text: Thomas A, Lee M, Mossburg S. Equity in Patient Safety. …

  4. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet

    psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery Citation Text: Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

  5. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. | PSNet

    psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
    November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery. Citation Text: Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49849/psn-pdf
    January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep January 1, 2019 Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep Case Objectives List the patient safety events that are unique to in…

  7. 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…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72911/psn-pdf
    March 15, 2021 - The Impact of Communication on Medication Errors March 15, 2021 Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors The Case   A 93-year-old man with a history of chronic systolic heart failure…

  9. Spotlight

    psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Intraoperative Awareness during Rhinoplasty 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Christian Bohringer MBBS and Jaijeet Toor MD AHRQ WebM&M Edit…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850361/psn-pdf
    June 14, 2023 - Critical Echocardiogram Result Lost to Follow-up June 14, 2023 Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow The Case A 63-year-old man with history of stroke, systolic heart failure, and ventric…

  11. A Lot of Pain (Medications) | PSNet

    psnet.ahrq.gov/web-mm/lot-pain-medications
    September 23, 2020 - SPOTLIGHT CASE A Lot of Pain (Medications) Citation Text: Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

  12. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions | PSNet

    psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
    November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions Lindsay E. Nicolle, MD | November 1, 2008  Also Read a Conversation View more articles from the same authors. Citation Text: Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Pr…

  13. In Conversation With... Heidi Wald, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-heidi-wald-md
    November 26, 2019 - In Conversation With... Heidi Wald, MD November 26, 2019  Also Read the Essay Citation Text: In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.In Conversation With... Heidi Wald, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …

  14. Critical Echocardiogram Result Lost to Follow-up | PSNet

    psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
    July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up Citation Text: Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Sch…

  15. Falling Through the Crack (in the Bedrails) | PSNet

    psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
    February 19, 2020 - SPOTLIGHT CASE Falling Through the Crack (in the Bedrails) Citation Text: Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation F…

  16. The Impact of Communication on Medication Errors | PSNet

    psnet.ahrq.gov/web-mm/impact-communication-medication-errors
    August 01, 2009 - The Impact of Communication on Medication Errors Citation Text: Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: …

  17. Missed Opportunities for Suicide Risk Assessment | PSNet

    psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
    September 27, 2023 - SPOTLIGHT CASE Missed Opportunities for Suicide Risk Assessment Citation Text: Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation For…

  18. Patient Safety in Frail Older Patients | PSNet

    psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
    November 26, 2019 - Patient Safety in Frail Older Patients November 26, 2019  Also Read the Conversation View more articles from the same authors. Citation Text: Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. Rockville (MD): Agency for Healthc…

  19. Spotlight Case Hindsight Is 2020 Slides Final Revised 05.03.2024 (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
    January 01, 2024 - 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 available o Commentary by: Eric Signoff, MD, Noelle Boctor, MD, and David K. B…

  20. Spotlight: Mistaken Attribution, Diagnostic Misstep | PSNet

    psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
    July 01, 2011 - SPOTLIGHT CASE Spotlight: Mistaken Attribution, Diagnostic Misstep Citation Text: Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citat…
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