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  1. psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
    February 26, 2025 - In Conversation With… Kaveh Shojania, MD November 1, 2015  Citation Text: In Conversation With… Kaveh Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60856/psn-pdf
    August 26, 2020 - Too Many Cooks in the Kitchen August 26, 2020 Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/too-many-cooks-kitchen Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Un…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837215/psn-pdf
    July 08, 2022 - Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. July 8, 2022 Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizure…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846169/psn-pdf
    March 15, 2023 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. March 15, 2023 Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/…
  5. 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…
  6. psnet.ahrq.gov/web-mm/privacy-or-safety
    December 01, 2011 - SPOTLIGHT CASE Privacy or Safety? Citation Text: Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…
  7. psnet.ahrq.gov/web-mm/dissecting-presentation
    May 05, 2021 - SPOTLIGHT CASE Dissecting the Presentation Citation Text: Suat-Ooi SB. Dissecting the Presentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 …
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866618/psn-pdf
    December 31, 2024 - A Fatal Twist in Pseudohyperkalemia December 31, 2024 Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for C…
  9. psnet.ahrq.gov/web-mm/perils-cross-coverage
    September 22, 2010 - SPOTLIGHT CASE The Perils of Cross Coverage Citation Text: Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX En…
  10. psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
    September 29, 2021 - SPOTLIGHT CASE Intraosseous Line Extravasation in a Pediatric Trauma Patient Citation Text: Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867429/psn-pdf
    December 18, 2024 - Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis December 18, 2024 Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. 2024. https://psnet.ahrq.gov/w…
  12. psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
    January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice Hardeep Singh, MD, MPH | January 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Singh H. Diagnostic Errors: A New Chapter in Patient Safe…
  13. psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
    September 01, 2017 - Assessing the Safety of Electronic Health Records: What Have We Learned? Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH | September 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Sittig DF, Singh H. Assessing the Safe…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857059/psn-pdf
    November 29, 2023 - The Risks of a Malpositioned Gastrostomy Tube and Poor Communication November 29, 2023 Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication Disclosure of Relevant Financial …
  15. psnet.ahrq.gov/perspective/ems-patient-safety-field
    July 28, 2021 - EMS Patient Safety in the Field July 28, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…
  16. psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
    February 01, 2006 - In Conversation with…John Banja, PhD February 1, 2006  Also Read an Essay Citation Text: In Conversation with…John Banja, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Ci…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49564/psn-pdf
    July 01, 2008 - Dependence vs. Pain July 1, 2008 Gordon AJ. Dependence vs. Pain . PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/dependence-vs-pain Case Objectives Define opioid dependence and opioid withdrawal syndrome. Describe the treatment of opioid withdrawal syndrome including the use of the Clinical Opioid Withdra…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33861/psn-pdf
    July 01, 2018 - In Conversation With… Gordon Schiff, MD July 1, 2018 In Conversation With… Gordon Schiff, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-gordon-schiff-md Editor's note: Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, Associate Pr…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33857/psn-pdf
    July 01, 2012 - In Conversation With… David Blumenthal, MD, MPP July 1, 2012 In Conversation With… David Blumenthal, MD, MPP. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0 Editor's note: Dr. Blumenthal is President of the Commonwealth Fund and served as the National Coordinator …
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49849/psn-pdf
    January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep January 1, 2019 Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep Case Objectives List the patient safety events that are unique to in…

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