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  1. psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Agitated Delirium_FINAL.pptx Spotlight Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation Source and Credits • This presentation is based on the March 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49721/psn-pdf
    December 01, 2014 - Ebola: Are We Ready? December 1, 2014 Barsuk JH, Barnard C. Ebola: Are We Ready? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/ebola-are-we-ready The Case A 28-year-old man, well-appearing but pale, walked into the emergency department (ED) on a Wednesday afternoon at 3 PM complaining of nausea, vomiting,…
  3. psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insulin-therapy
    July 01, 2008 - Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy Citation Text: Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
  4. 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…
  5. psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
    September 01, 2004 - SPOTLIGHT CASE Unintended Consequences of CPOE Citation Text: Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNot…
  6. psnet.ahrq.gov/classics
    August 01, 2023 - Classics and Emerging Classics To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient sa…
  7. psnet.ahrq.gov/curated-library/diagnostic-safety-improvement
    September 14, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Diagnostic Safety Improvement  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNe…
  8. psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
    August 05, 2022 - Duplicate Therapies in Retail Pharmacy Citation Text: Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX E…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49553/psn-pdf
    January 01, 2008 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures January 1, 2008 Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures The…
  10. psnet.ahrq.gov/curated-library/maternal-safety
    January 31, 2024 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Maternal Safety  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team …
  11. psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
    November 16, 2022 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures Citation Text: Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
  12. psnet.ahrq.gov/web-mm/isolated-clot-real-error
    December 01, 2013 - SPOTLIGHT CASE Isolated Clot, Real Error Citation Text: Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  13. psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
    February 01, 2012 - by the nurse in charge of the patient, and all the involved teams are expected to have at least one member
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42535/psn-pdf
    October 16, 2013 - Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members. October 16, 2013 Jeffs L, Abramovich IA, Hayes C, et al. Implementing an interprofessional patient safety learning initiative: insights from participants, project leads an…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40275/psn-pdf
    March 23, 2011 - Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. March 23, 2011 Wauben LSGL, van Doorn CMD-, van Wijngaarden JDH, et al. Discrepant perceptions of communication, teamwork and situation awareness among surgical team members. Int J Qual Health Care. 2011;23(2):15…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49423/psn-pdf
    November 01, 2003 - The Missing Suction Tip November 1, 2003 Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missing-suction-tip Case Objectives Identify the risk factors for retained foreign bodies. Understand methods used to prevent and identify retained foreign bodies. Apprecia…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47555/psn-pdf
    November 14, 2018 - How one hospital improved patient safety in 10 minutes a day. November 14, 2018 van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018. https://psnet.ahrq.gov/issue/how-one-hospital-improved-patient-safety-10-minutes-day Aviation continues to provide inspiration for patient safety innovation. This commentar…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34839/psn-pdf
    April 06, 2011 - Communication failures in the operating room: an observational classification of recurrent types and effects. April 6, 2011 Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13(5):330-4. http…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45031/psn-pdf
    February 18, 2017 - Information transfer in multidisciplinary operating room teams: a simulation-based observational study. February 18, 2017 Cumin D, Skilton C, Weller J. Information transfer in multidisciplinary operating room teams: a simulation- based observational study. BMJ Qual Saf. 2017;26(3):209-216. doi:10.1136/bmjqs-2015-00…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42638/psn-pdf
    October 09, 2013 - Strengths and weaknesses of working with the Global Trigger Tool method for retrospective record review: focus group interviews with team members. October 9, 2013 Schildmeijer K, Nilsson L, Perk J, et al. Strengths and weaknesses of working with the Global Trigger Tool method for retrospective record review: focus…

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