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  1. Death by PCA | PSNet

    psnet.ahrq.gov/web-mm/death-pca
    January 06, 2017 - Death by PCA Citation Text: Hicks RW. Death by PCA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

  2. Errors in Sepsis Management | PSNet

    psnet.ahrq.gov/web-mm/errors-sepsis-management
    November 03, 2015 - SPOTLIGHT CASE Errors in Sepsis Management Citation Text: Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X…

  3. Tough Call: Addressing Errors From Previous Providers | PSNet

    psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
    July 17, 2024 - SPOTLIGHT CASE Tough Call: Addressing Errors From Previous Providers Citation Text: Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy…

  4. Project BOOST Increases Patient Understanding of Treatment and Follow-up Care | PSNet

    psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
    February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 26, 2021 Innovation Contact …

  5. Duplicate Insulin Order | PSNet

    psnet.ahrq.gov/web-mm/duplicate-insulin-order
    May 04, 2012 - Duplicate Insulin Order Citation Text: Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  6. E-cigarette Explosion in a Patient Room | PSNet

    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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

  7. Novel Drug Misuse | PSNet

    psnet.ahrq.gov/web-mm/novel-drug-misuse
    September 30, 2010 - SPOTLIGHT CASE Novel Drug Misuse Citation Text: Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

  8. Organizational Learning | PSNet

    psnet.ahrq.gov/curated-library/organizational-learning
    November 10, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Organizational Learning  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…

  9. Communication During Transitions of Care | PSNet

    psnet.ahrq.gov/perspective/communication-during-transitions-care
    July 10, 2024 - Annual Perspective Communication During Transitions of Care Ayse P. Gurses; Sarah Mossburg; Zoe Sousane | March 27, 2024  View more articles from the same authors. Citation Text: Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…

  10. Nursing and Patient Safety | PSNet

    psnet.ahrq.gov/primer/nursing-and-patient-safety
    September 15, 2024 - Nursing and Patient Safety Citation Text: Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

  11. Privacy or Safety? | PSNet

    psnet.ahrq.gov/web-mm/privacy-or-safety
    December 01, 2011 - SPOTLIGHT CASE Privacy or Safety? Citation Text: Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

  12. In Conversation With… Michael Cohen, RPh, MS, ScD (hon) | PSNet

    psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
    October 24, 2021 - In Conversation With… Michael Cohen, RPh, MS, ScD (hon) October 1, 2018  Citation Text: In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  13. Misplaced Nasogastric Tube Resulting in Aspiration | PSNet

    psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
    August 01, 2009 - Misplaced Nasogastric Tube Resulting in Aspiration Citation Text: Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google S…

  14. But See the Patient First | PSNet

    psnet.ahrq.gov/web-mm/see-patient-first
    September 27, 2023 - But See the Patient First Citation Text: Sinigayan VR. But See the Patient First. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…

  15. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure | PSNet

    psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
    March 01, 2005 - SPOTLIGHT CASE CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure Citation Text: Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857258/psn-pdf
    November 30, 2023 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon November 30, 2023 Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/always-check-muscle-twitch-…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33793/psn-pdf
    November 01, 2015 - In Conversation With… Kaveh Shojania, MD November 1, 2015 In Conversation With… Kaveh Shojania, MD. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md Editor's note: Kaveh Shojania, MD, is Editor-in-Chief of BMJ Quality and Safety and Director of the Centre for Quality Impro…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33708/psn-pdf
    March 01, 2011 - In Conversation with…Vineet Arora, MD, MA March 1, 2011 In Conversation with…Vineet Arora, MD, MA . PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma Editor's note: Vineet Arora, MD, MA, is Associate Program Director for the Internal Medicine Residency and Assistant Dea…

  19. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis | PSNet

    psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
    January 13, 2010 - SPOTLIGHT CASE A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis Citation Text: Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33863/psn-pdf
    August 01, 2018 - In Conversation With… Matthew Weinger, MD August 1, 2018 In Conversation With… Matthew Weinger, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-matthew-weinger-md Editor's note: Dr. Weinger is Director of the Center for Research and Innovation in Systems Safety and Professor of Anesthes…
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