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psnet.ahrq.gov/node/33649/psn-pdf
May 01, 2007 - In Conversation with...Sir Liam Donaldson, MD, MSc
May 1, 2007
In Conversation with..Sir Liam Donaldson, MD, MSc. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
Editor's Note: Sir Liam Donaldson, MD, MSc, is England's Chief Medical Officer, a post often referre…
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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - Spotlight
Spotlight
"Do You Want Everything Done?":
Clarifying Code Status
Source and Credits
• This presentation is based on the December 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus
M…
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psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - Perils in Diagnosing a Stroke
June 1, 2018
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
The Case
A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was
brought to the emergency depart…
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psnet.ahrq.gov/node/33722/psn-pdf
December 01, 2011 - In Conversation With… Ann L. Hendrich, RN, PhD
December 1, 2011
In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
Editor's note: Ann L. Hendrich, RN, PhD, is Vice President of Clinical Excellence Operations and
Executive Di…
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psnet.ahrq.gov/node/33820/psn-pdf
December 01, 2016 - In Conversation With... James P. Bagian, MD, PE
December 1, 2016
In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
Editor's note: Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the
Uni…
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psnet.ahrq.gov/node/49856/psn-pdf
March 01, 2019 - Premature Extubation
March 1, 2019
Sagana R, Hyzy RC. Premature Extubation. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/premature-extubation
The Case
A 73-year-old woman with a history of carotid artery stenosis was admitted for an elective carotid
endarterectomy. The procedure was initially thought to …
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Lost in the Black Hole
Citation Text:
Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
May 01, 2011 - Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention
Citation Text:
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Cop…
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psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
February 26, 2025 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis
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May 31, 2023
Innovation
Contact
…
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - Glucose Roller Coaster
Citation Text:
Sharpe B. Glucose Roller Coaster. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/60330/psn-pdf
May 05, 2020 - Telehealth and Patient Safety During the COVID-19
Response
May 14, 2020
Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
Introduction
Telehealth typ…
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psnet.ahrq.gov/node/836978/psn-pdf
May 16, 2022 - Check Twice, Transport Once
May 16, 2022
DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/check-twice-transport-once
The Case
Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal
pain and was diagnosed with “s…
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - Two Pills, Same Drug
Citation Text:
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/49817/psn-pdf
January 01, 2018 - Slow Down: Right Drug, Wrong Formulation
January 1, 2018
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
The Case
A 65-year-old man presented to his primary care clinic for follow-up after a recent hospitaliz…
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psnet.ahrq.gov/perspective/context-intervention
August 05, 2020 - The Context Is the Intervention
Dr. John Øvretveit | October 1, 2011
View more articles from the same authors.
Citation Text:
Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - The Dropped Lung
Citation Text:
Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/node/33597/psn-pdf
April 10, 2024 - Long-term Care and Patient Safety
April 10, 2024
Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/long-term-care-and-patient-safety
Background
For many years, the patient safety field focused on improving safety in hospital and ambulatory care
settings. More re…
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - Missing Trauma
Citation Text:
Jurkovich GJ. Missing Trauma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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…
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psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
January 07, 2015 - Dropping the Ball Despite an Integrated EMR
Citation Text:
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/838972/psn-pdf
October 27, 2022 - The Unhappy Patient Leaves Against Medical Advice.
October 27, 2022
Nichols A. The Unhappy Patient Leaves Against Medical Advice. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
The Case
A 61-year-old woman was placed on bedrest following major surgery. Her posto…