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  1. Root Cause Analysis | PSNet

    psnet.ahrq.gov/primer/root-cause-analysis
    March 30, 2022 - Root Cause Analysis Citation Text: Root Cause Analysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865309/psn-pdf
    May 29, 2024 - A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care May 29, 2024 Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post- Tracheostomy Care. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-i…

  3. Consequences of Medical Overuse | PSNet

    psnet.ahrq.gov/web-mm/consequences-medical-overuse
    May 05, 2021 - SPOTLIGHT CASE Consequences of Medical Overuse Citation Text: Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50613/psn-pdf
    October 30, 2019 - In Conversation With… Neel Shah, MD, MPP October 30, 2019 In Conversation With… Neel Shah, MD, MPP. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp Editor's note: Dr. Shah, MD, MPP, is an Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medi…

  5. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications | PSNet

    psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
    February 01, 2004 - SPOTLIGHT CASE Delay in Treatment: Failure to Contact Patient Leads to Significant Complications Citation Text: Shapiro DS. Delay in Treatment: Failure to Contact Patient Leads to Significant Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departmen…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50754/psn-pdf
    December 18, 2019 - "Do You Want Everything Done?": Clarifying Code Status December 18, 2019 Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status Disclosure of Relevant Financial Relationships: As a p…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861760/psn-pdf
    January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33863/psn-pdf
    August 01, 2018 - In Conversation With… Matthew Weinger, MD August 1, 2018 In Conversation With… Matthew Weinger, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-matthew-weinger-md Editor's note: Dr. Weinger is Director of the Center for Research and Innovation in Systems Safety and Professor of Anesthes…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33692/psn-pdf
    February 01, 2010 - In Conversation with…Thomas J. Nasca, MD February 1, 2010 In Conversation with…Thomas J. Nasca, MD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md Editor's note: Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council fo…

  10. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/865308
    January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Organizational Learning Curated Library Foundations Organizational learning: health care leaders need to design structures and processes that enhance collective learning. Bohmer RM, Edmondson AC. Health Forum J. 2001;44:32-35. This comment…

  11. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/854855
    January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Patient as a Team Member in Clinical Care Curated Library Foundations Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving Patient Safety. Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, F…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33716/psn-pdf
    September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD September 1, 2011 In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md Editor's note: Kaveh G. Shojania, MD, is the Canada Research Chair in Patient Safety and Quality Improvement and t…

  13. Patient as a Team Member in Clinical Care | PSNet

    psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
    March 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Patient as a Team Member in Clinical Care  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybraria…

  14. Do Not Disturb! | PSNet

    psnet.ahrq.gov/web-mm/do-not-disturb
    February 03, 2011 - SPOTLIGHT CASE Do Not Disturb! Citation Text: Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

  15. Hypoxemia after Emergency Intubation | PSNet

    psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation
    March 24, 2019 - Hypoxemia after Emergency Intubation Citation Text: Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  16. Implementation of Patient Safety Projects | PSNet

    psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
    August 10, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Implementation of Patient Safety Projects  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybraria…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867357/psn-pdf
    December 18, 2024 - Hypoxemia after Emergency Intubation December 18, 2024 Bohringer C, Liu H. Hypoxemia after Emergency Intubation. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hypoxemia-after-emergency-intubation The Case A 19-month-old child was brought to the emergency department (ED) via ambulance after drowning in a p…

  18. The Media’s Role in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/medias-role-patient-safety
    April 27, 2022 - The Media’s Role in Patient Safety April 27, 2022  Also Read the Conversation View more articles from the same authors. Citation Text: Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcar…

  19. In Conversation With… Michelle Mello, MPhil, JD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
    July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD July 1, 2017  Also Read an Essay Citation Text: In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Hum…

  20. In Conversation With… Richard Hoppmann, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md
    June 01, 2018 - In Conversation With… Richard Hoppmann, MD June 1, 2018  Also Read an Essay Citation Text: In Conversation With… Richard Hoppmann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
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