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  1. psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
    November 26, 2019 - Patient Safety in Frail Older Patients November 26, 2019  Also Read the Conversation View more articles from the same authors. Citation Text: Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. Rockville (MD): Agency for Healthc…
  2. psnet.ahrq.gov/web-mm/tale-two-falls
    March 27, 2024 - A Tale of Two Falls Citation Text: Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
  3. 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 …
  4. psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
    September 27, 2023 - SPOTLIGHT CASE Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Citation Text: Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.. PSNet [internet]…
  5. psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
    September 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012  Also Read an Essay Citation Text: In Conversation With… Jack Needleman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867035/psn-pdf
    October 30, 2024 - A Tale of Two Falls October 30, 2024 Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/tale-two-falls The Cases Case #1: A 79-year-old woman with a history of impaired cognition at baseline was brought from a skilled nursing facility to the emergency department (ED) f…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866370/psn-pdf
    July 31, 2024 - Intraoperative Awareness during Rhinoplasty July 31, 2024 Bohringer C, Toor J. Intraoperative Awareness during Rhinoplasty. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation …
  8. psnet.ahrq.gov/perspective/role-national-quality-forum-nqf-quest-transparency-us-hospitals-patient-safety
    April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance Lance L. Roberts, MS; Marcia M. Ward, PhD; Thomas C. Evans, MD | April 1, 2010  Also Read a Conversation View more articles from the same authors. …
  9. psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
    August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers Chayan Chakraborti, MD; Marc J. Kahn, MD; N. Kevin Krane, MD | August 1, 2010  Also Read a Conversation View more articles from the same authors. Citation Text: Chakraborti C, Kahn MJ, Krane K. Operatio…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865419/psn-pdf
    March 27, 2024 - Do Not Miss Sepsis Needles in Viral Haystacks! March 27, 2024 Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks Disclosure of Relevant Financial Relationships: As a provider accredited by the Accredit…
  11. psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
    January 01, 2021 - Microsoft PowerPoint - FINAL Feb 2021 Spotlight_Delay in Appropriate DX.pptx - Read-Only Spotlight Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism Source and Credits • This presentation is based on the February 2021 AHRQ WebM&M Spotlight Case o See the full article at ht…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867428/psn-pdf
    December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-patricia-dykes-a…
  13. AHRQ PSNet Webinar (pdf file)

    psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
    January 01, 2025 - AHRQ PSNet Webinar AHRQ PSNet Webinar Making Healthcare Safer (MHS) IV: Rapid Response Systems and Opioid Stewardship February 10, 2025 Agenda 2 • Logistics • Introduction to the Making Healthcare Safer (MHS) IV Reports • Report 1 – Rapid Response Systems ► Discussion ► PSNet Resources • Report 2 – Opioi…
  14. psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
    October 31, 2023 - SPOTLIGHT CASE Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. Citation Text: Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74120/psn-pdf
    November 30, 2021 - Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care November 30, 2021 Spero H, Usher AE, Howard B, et al. Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care . PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/culture-clash-no-mo…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/864867/psn-pdf
    April 10, 2024 - Hindsight is 20/20: Thrombolytics for Alcohol Intoxication April 10, 2024 Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication Disclosure of Relevant Financial Relationships: As a provider accredited by th…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853902/psn-pdf
    September 27, 2023 - A Missed Bowel Perforation - the Importance of Diagnostic Reasoning September 27, 2023 Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning Disclosure of …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843234/psn-pdf
    January 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts. February 1, 2023 Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive D…
  19. psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
    March 27, 2024 - SPOTLIGHT CASE Do Not Miss Sepsis Needles in Viral Haystacks! Citation Text: Hamline M, Shaikh U. Do Not Miss Sepsis Needles in Viral Haystacks!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation For…
  20. 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…

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