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  1. psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
    January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care Paul E. Plsek, MS | January 1, 2015  Also Read a Conversation View more articles from the same authors. Citation Text: Plsek PE. Innovation and Lean Thinking: Mutuall…
  2. psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
    January 01, 2015 - In Conversation With… Mark Graban, MS, MBA January 1, 2015  Also Read an Essay Citation Text: In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015…
  3. psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
    August 01, 2006 - Getting Into Patient Safety: A Personal Story Jeffrey B. Cooper, PhD | August 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. Rockville (MD): A…
  4. psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
    March 22, 2009 - The Role of Health Literacy in Patient Safety Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH | March 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866839/psn-pdf
    September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations September 25, 2024 Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
  6. psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
    January 01, 2024 - Spotlight Spotlight Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations 1 Source and Credits This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: David…
  7. psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx Spotlight The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Source and Credits • This presentation is based on the November 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahr…
  8. psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
    April 01, 2018 - Patient Safety During Hospital Discharge Katherine Liang and Eric Alper, MD | April 1, 2018  Also Read a Conversation View more articles from the same authors. Citation Text: Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. Rockville…
  9. psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
    May 01, 2013 - In Conversation With… Ashish K. Jha, MD, MPH May 1, 2013  Also Read an Essay Citation Text: In Conversation With… Ashish K. Jha, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013…
  10. psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
    December 01, 2009 - In Conversation with…Gerald B. Hickson, MD December 1, 2009  Also Read an Essay Citation Text: In Conversation with…Gerald B. Hickson, MD . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
  11. psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
    April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM April 1, 2018  Also Read an Essay Citation Text: In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
  12. psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
    December 01, 2009 - How to Identify and Manage Problem Behaviors Alan H. Rosenstein, MD, MBA; Michelle O'Daniel, MSG, MHA | December 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Rosenstein AH, O'Daniel M. How to Identify and Manage Prob…
  13. psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
    April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety? Kathlyn E. Fletcher, MD, MA; Darcy A. Reed, MD, MPH | April 1, 2013  Also Read a Conversation View more articles from the same authors. Citation Text: Fletcher KE, Reed DA. Are Residency Duty Hour Rules Imp…
  14. psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
    February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Vogus T, Lee M, Mos…
  15. psnet.ahrq.gov/perspective/health-equity-and-maternal-health
    October 06, 2021 - Health Equity and Maternal Health October 6, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. Rockville (MD): Agency for Healthcare…
  16. psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
    February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Essay View more articles from the same authors. Ci…
  17. psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
    August 01, 2012 - SPOTLIGHT CASE The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Citation Text: Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
  18. psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
    November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions Pascale Carayon, PhD; Nicole Werner, PhD; Anita Makkenchery, MPH; Sarah E. Mossburg, RN, PhD | November 16, 2022  Also Read the Conversation View more articles from the same aut…
  19. psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
    November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD November 16, 2022  Also Read the Essay Citation Text: In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.In Conversation With... Pascale Carayon, PhD and Ni…
  20. psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
    September 27, 2023 - SPOTLIGHT CASE Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations Citation Text: Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…

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