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psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
March 27, 2024 - SPOTLIGHT CASE
         
 Hidden Heparins: HIT Happens 
 
 
 
 
 Citation Text: 
 Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. 
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - SPOTLIGHT CASE
         
 Difficult Encounters: A CMO and CNO Respond 
 
 
 
 
 Citation Text: 
 Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. 
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such … 
                                     
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psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md
February 26, 2025 - In Conversation With… Shantanu Nundy, MD 
 July 1, 2018 
                       
 
 
 
 
 
 
 
 
 
 
 
 
 Citation Text: 
 In Conversation With… Shantanu Nundy, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. 
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psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
May 28, 2020 - The Role of the FDA in Ensuring Device Safety  
 May 28, 2020 
                       
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 Citation Text: 
 Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. Rockville (MD): Agency f… 
                                     
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - SPOTLIGHT CASE
         
 Getting to the Root of the Matter 
 
 
 
 
 Citation Text: 
 Saint S, Flanders S. Getting to the Root of the Matter. 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/web-mm/robotic-surgery-risks-vs-rewards
October 31, 2023 - SPOTLIGHT CASE
         
 Robotic Surgery: Risks vs. Rewards 
 
 
 
 
 Citation Text: 
 Kirkpatrick T, LaGrange C. Robotic Surgery: Risks vs. Rewards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. 
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psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - If you administer opioids and naloxone in the same record, perhaps the dose was too large, or untreated
                                     
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psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
September 13, 2023 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use 
 
 
 
 
 
 
 
 
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psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
June 29, 2020 - In Conversation With... Anna Legreid Dopp, Pharm. D 
 June 29, 2020 
                       
 
 
 
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 Citation Text: 
 In Conversation With.. Anna Legreid Dopp, Pharm. D. PSNet [internet]. 2020.In Conversation With... Anna Legreid Dopp, Pharm. D. PSNet [internet]. Rockville (MD): … 
                                     
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The Problem and Solutions 
 Lindsay E. Nicolle, MD  | November 1, 2008 
                       
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 Citation Text: 
 Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Pr… 
                                     
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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 … 
                                     
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - Safety Across The Board  
 August 31, 2020 
                       
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 Citation Text: 
 Fitall E, Hall KK, Gale B. Safety Across The Board . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De… 
                                     
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - Artificial Intelligence and Diagnostic Errors 
 January 31, 2020 
                       
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 Citation Text: 
 Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Hea… 
                                     
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - If you administer opioids and naloxone in the same record, perhaps the dose was too large, or untreated
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - Interpreting the Patient Safety Literature 
 Kaveh G. Shojania, MD | June 1, 2005 
                       
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 Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. Rockville (MD): Agency f… 
                                     
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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-… 
                                     
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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - Primary Care and Patient Safety: Opportunities at the
Interface
September 28, 2022
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
Editor’s Not… 
                                     
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges 
 Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT 
 | April 24, 2024 
                       
 
 
 
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 Leary KB. In Con… 
                                     
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia 
 
 
 
 
 Citation Text: 
 Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…