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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33594/psn-pdf
    November 18, 2021 - Measures should be taken to promote the comfort of those present as well as the equality of all participants
  2. psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
    March 18, 2020 - Some preemptive measures include thorough preoperative risk assessment and preoperative fasting.
  3. psnet.ahrq.gov/perspective/conversation-charles-ornstein
    October 01, 2009 - This focus was provided in large measure by the media.
  4. psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
    October 01, 2009 - This focus was provided in large measure by the media.
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851870/psn-pdf
    July 31, 2023 - what happened to bring attention to this risk through our safety alert program and other marketing measures—all
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72739/psn-pdf
    February 10, 2021 - Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism February 10, 2021 McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leadi…
  7. psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
    July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes Ross Koppel, PhD | July 1, 2012  Also Read a Conversation View more articles from the same authors. Citation Text: Koppel R. Patient Safety and Health Information Technology: Learning f…
  8. psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp
    July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP July 1, 2012  Also Read an Essay Citation Text: In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
  9. psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
    December 31, 2024 - SPOTLIGHT CASE Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism Citation Text: McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49687/psn-pdf
    August 21, 2013 - Emergency Error August 21, 2013 Symons NRA. Emergency Error. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/emergency-error Case Objectives State that emergency surgery is high risk and has high mortality. Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of …
  11. psnet.ahrq.gov/web-mm/missing-suction-tip
    January 01, 2006 - SPOTLIGHT CASE The Missing Suction Tip Citation Text: Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33717/psn-pdf
    September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please September 1, 2011 Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please …
  13. psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
    April 24, 2018 - The Fluidity of Diagnostic "Wet Reads" Citation Text: Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49568/psn-pdf
    September 01, 2008 - Failure to Latch September 1, 2008 Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/failure-latch The Case The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to breastfeeding exclusively for 6 months. However, early br…
  15. psnet.ahrq.gov/web-mm/medical-devices-wild
    March 27, 2024 - Medical Devices in the "Wild" Citation Text: Gurses AP, Doyle PA. Medical Devices in the "Wild". 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 XML EndNote 7 …
  16. psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
    February 26, 2025 - In Conversation With… Erik Hollnagel, PhD June 1, 2019  Citation Text: In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Forma…
  17. psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
    January 07, 2015 - Haste Makes Care Unsafe Citation Text: Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72618/psn-pdf
    December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care December 23, 2020 https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards- medical-decisions Summary Nudges are a change in the way choices ar…
  19. psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
    August 15, 2018 - Acute Respiratory Arrest in Pregnancy Citation Text: Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…
  20. psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
    October 01, 2011 - SPOTLIGHT CASE Abdominal Aortic Aneurysm Screening Citation Text: Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX E…

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