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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - SPOTLIGHT CASE
Discharge Fumbles
Citation Text:
Forster AJ. Discharge Fumbles. 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/web-mm/code-status-confusion
September 01, 2006 - SPOTLIGHT CASE
Code Status Confusion
Citation Text:
Lo B, Tulsky JA. Code Status Confusion. 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/e-cigarette-explosion-patient-room
March 15, 2023 - E-cigarette Explosion in a Patient Room
Citation Text:
Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - SPOTLIGHT CASE
Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.
Citation Text:
Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
October 28, 2020 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
Citation Text:
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/perspective/conversation-elizabeth-salisbury-afshar-about-harm-reduction-strategies-improve-safety
October 30, 2024 - In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024
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psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
October 30, 2024 - Harm Reduction Strategies to Improve Safety for People Who Use Substances
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Salisbury-…
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psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
August 01, 2012 - safety risk to yourself, your family, others in the building, and then you almost have very little option
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - Managing Ascites: Hazards of Fluid Removal
Citation Text:
Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
February 24, 2022 - dental care can also lead to untreated tooth decay or other infections, leaving people with no viable option
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psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - Annual Perspective
Technology as a Tool for Improving Patient Safety
A Jay Holmgren, Susan McBride,Bryan Gale, Sarah Mossburg
| March 29, 2023
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Citation Text:
Holmgren AJ, McBride S, Gale B, et al. Technology as a …
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psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
December 08, 2021 - SPOTLIGHT CASE
When Patients and Providers Speak Different Languages
Citation Text:
Karliner LS. When Patients and Providers Speak Different Languages. 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/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.
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psnet.ahrq.gov/node/867986/psn-pdf
March 24, 2025 - But the other option is to make the room as safe as possible, removing all the
equipment that can be
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it
August 01, 2012 - safety risk to yourself, your family, others in the building, and then you almost have very little option
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - SPOTLIGHT CASE
Multifactorial Medication Mishap
Citation Text:
Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - SPOTLIGHT CASE
Palliative Care: Comfort vs. Harm
Citation Text:
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - SPOTLIGHT CASE
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.
Citation Text:
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…