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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - The security measures required are significantly higher than maintained by many organizations, and there
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/need-eat
February 10, 2021 - The Need to Eat
Citation Text:
Widaman AM. The Need to Eat. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/50755/psn-pdf
December 18, 2019 - The Need to Eat
December 18, 2019
Widaman AM. The Need to Eat. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/need-eat
The Case
A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder
caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…
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psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes
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December 22, 2020
Innovation
Contact
…
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - In Conversation With… Mark L. Graber, MD
January 1, 2016
In Conversation With… Mark L. Graber, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
Editor's note: Dr. Graber is a Senior Fellow at RTI International and Professor Emeritus of Medicine at
the State University o…
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - WebM&M: Case Studies
WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - In Conversation With… Jack Needleman, PhD
September 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… Jack Needleman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012…
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psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
January 31, 2024 - Like other safety improvement measures, such changes could be applied in a variety of settings.
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - copy-and-paste function is technically feasible within the EHR itself, clinicians typically oppose such drastic measures
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psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
January 31, 2024 - Like other safety improvement measures, such changes could be applied in a variety of settings.
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - experience negative emotional reactions to strangers and
pain.6
Levels of sedation
Nearly all sedation scales
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - AHRQ PSNet Webinar
AHRQ PSNet Webinar
Making Healthcare Safer (MHS) IV:
Rapid Response Systems and Opioid Stewardship
February 10, 2025
Agenda
2
• Logistics
• Introduction to the Making Healthcare Safer (MHS) IV Reports
• Report 1 – Rapid Response Systems
► Discussion
► PSNet Resources
• Report 2 – Opioi…
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psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation?
Ashish K. Jha, MD, MPH | September 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Jha AK. What Can the Rest of the Heal…
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psnet.ahrq.gov/node/855058/psn-pdf
October 31, 2023 - In Conversation with... Cheryl Jones about Addressing
Workplace Violence and Creating a Safer Workplace
October 31, 2023
Jones CB. In Conversation with.. Cheryl Jones about Addressing Workplace Violence and Creating a Safer
Workplace. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-cheryl-j…
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - Intraosseous Line Extravasation in a Pediatric Trauma
Patient
April 27, 2022
Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/node/853902/psn-pdf
September 27, 2023 - A Missed Bowel Perforation - the Importance of
Diagnostic Reasoning
September 27, 2023
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
Disclosure of …
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - SPOTLIGHT CASE
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
Citation Text:
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…