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  1. psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
    September 01, 2003 - SPOTLIGHT CASE Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough Citation Text: Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846171/psn-pdf
    July 26, 2022 - Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation March 15, 2023 Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/agitated-delirium-contributes…
  3. psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
    October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…
  4. psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
    March 27, 2024 - SPOTLIGHT CASE Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head Citation Text: Martin R, Shahlaie K. Delayed Symptomatic Subdural Hematoma Following an Initially Normal CT Head. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
  5. psnet.ahrq.gov/primer/maternal-safety
    January 10, 2024 - Maternal Safety Citation Text: Shauer M, Nichols A, Lyndon A. Maternal Safety. 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 XML EndNote 7 XML Endnote tagged…
  6. 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…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867035/psn-pdf
    October 30, 2024 - A Tale of Two Falls October 30, 2024 Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/tale-two-falls The Cases Case #1: A 79-year-old woman with a history of impaired cognition at baseline was brought from a skilled nursing facility to the emergency department (ED) f…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866370/psn-pdf
    July 31, 2024 - Intraoperative Awareness during Rhinoplasty July 31, 2024 Bohringer C, Toor J. Intraoperative Awareness during Rhinoplasty. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865419/psn-pdf
    March 27, 2024 - Do Not Miss Sepsis Needles in Viral Haystacks! March 27, 2024 Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks Disclosure of Relevant Financial Relationships: As a provider accredited by the Accredit…
  10. psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
    November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again John Gosbee, MD, MS | November 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Aga…
  11. AHRQ PSNet Webinar (pdf file)

    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…
  12. 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…
  13. psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
    February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc October 30, 2019  Citation Text: In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852807/psn-pdf
    August 30, 2023 - Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia August 30, 2023 Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-…
  15. psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
    March 27, 2024 - In Conversation With… John Halamka, MD, MS May 1, 2018  Citation Text: In Conversation With… John Halamka, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Form…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841467/psn-pdf
    December 14, 2022 - A framework for assessing reasoning about controversial end-of-life clinical decisions. December 14, 2022 Fedyk M, Fairman N, Romano PS, et al. A framework for assessing reasoning about controversial end-of- life clinical decisions. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/framework-assessing-reasonin…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837913/psn-pdf
    August 31, 2022 - Miscommunication During the Interhospital Transport of a Critically Ill Child August 31, 2022 Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-c…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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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