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  1. psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
    February 01, 2014 - So we're working on accelerating patient safety improvement in nursing homes and in ambulatory care—particularly
  2. psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
    October 24, 2021 - In Conversation With… Michael Cohen, RPh, MS, ScD (hon) October 1, 2018  Citation Text: In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865884/psn-pdf
    May 29, 2024 - Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. May 29, 2024 Olson APJ. Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-…
  4. psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
    May 01, 2018 - SPOTLIGHT CASE Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency Citation Text: Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  5. psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
    September 25, 2024 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected Citation Text: Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49660/psn-pdf
    August 01, 2012 - No News May Not Be Good News August 1, 2012 Moore CR. No News May Not Be Good News. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news Case Objectives Describe the frequency with which ambulatory test results are not followed up by providers. Appreciate that inadequate follow-up of…
  7. psnet.ahrq.gov/web-mm/missed-appendicitis
    March 13, 2013 - SPOTLIGHT CASE Missed Appendicitis Citation Text: Adams JG. Missed Appendicitis. 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 XML EndNote 7 XML E…
  8. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_latex_allergies-slides.pdf
    January 01, 2022 - Spotlight Spotlight Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy Source and Credits • This presentation is based on the August 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by K…
  9. psnet.ahrq.gov/perspective/conversation-maureen-bisognano
    February 26, 2025 - In Conversation With… Maureen Bisognano June 1, 2015  Citation Text: In Conversation With… Maureen Bisognano. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49655/psn-pdf
    June 01, 2012 - A Painful Dilemma June 1, 2012 Davison SN. A Painful Dilemma. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/painful-dilemma The Case A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49851/psn-pdf
    January 01, 2019 - One Bronchoscopy, Two Errors January 1, 2019 Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors The Case A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic respiratory failure…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33745/psn-pdf
    February 01, 2013 - Patient Engagement and Patient Safety February 1, 2013 Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety Perspective Patient engagement has arrived at the station. A Google search of this phrase identified 335,000 hi…
  13. psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
    September 27, 2023 - Timely diagnosis of esophageal perforation Citation Text: Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Format: Google Scholar BibTeX …
  14. psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
    January 01, 2015 - If You Say So: Taking a Syringe at Face Value in the Operating Room Citation Text: Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cita…
  15. psnet.ahrq.gov/web-mm/e-prescribing-e-error
    February 03, 2021 - SPOTLIGHT CASE E-prescribing: E for error? Citation Text: Ashton EW. E-prescribing: E for error?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…
  16. psnet.ahrq.gov/web-mm/risks-absent-interoperability-medication-induced-hemolysis-patient-known-allergy
    April 08, 2019 - SPOTLIGHT CASE The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy Citation Text: Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcar…
  17. psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
    July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up Citation Text: Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Sch…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33826/psn-pdf
    February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM February 1, 2017 In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am Editor's note: Dr. Edmondson is professor of Leadership and Management at Harvard Business School. Her la…
  19. psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
    August 20, 2018 - Fever response in elderly nursing home residents: are the older truly colder?
  20. psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
    December 15, 2024 - September 28, 2022 Communication disparities between nursing home team members.

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