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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33706/psn-pdf
    February 01, 2011 - In Conversation with...Brent C. James, MD, MStat February 1, 2011 In Conversation with..Brent C. James, MD, MStat. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat Editor's note: Brent C. James, MD, MStat, is Chief Quality Officer and Executive Director of the Insti…
  2. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33692/psn-pdf
    February 01, 2010 - In Conversation with…Thomas J. Nasca, MD February 1, 2010 In Conversation with…Thomas J. Nasca, MD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md Editor's note: Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council fo…
  4. psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
    January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx Spotlight A Loss of Trust and a Missed Diagnosis Source and Credits • This presentation is based on the February 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.…
  5. psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
    November 13, 2024 - Delayed Diagnosis of Endocrinologic Emergencies Citation Text: Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33759/psn-pdf
    October 01, 2012 - Promising Areas for Patient Safety Research December 1, 2003 Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. PSNet [internet]. 2003. https://psnet.ahrq.gov/perspective/promising-areas-patient-safety-research Perspective Setting a Course for Patient Safety Research Although patient safety…
  7. psnet.ahrq.gov/web-mm/delirium-or-dementia
    September 27, 2023 - SPOTLIGHT CASE Delirium or Dementia? Citation Text: Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/861760/psn-pdf
    January 31, 2024 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery January 31, 2024 Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33760/psn-pdf
    February 01, 2014 - In Conversation With… Enrico Coiera, MB, BS, PhD February 1, 2014 In Conversation With… Enrico Coiera, MB, BS, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd Editor's note: Enrico Coiera, MB, BS, PhD, is a professor and director of the Centre for Health Informa…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33752/psn-pdf
    August 01, 2013 - In Conversation With… J. Bryan Sexton, PhD, MA August 1, 2013 In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma Editor's note: J. Bryan Sexton, PhD, is associate professor and director of the Patient Safety Center for the D…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33716/psn-pdf
    September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD September 1, 2011 In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md Editor's note: Kaveh G. Shojania, MD, is the Canada Research Chair in Patient Safety and Quality Improvement and t…
  12. psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
    February 01, 2011 - The University of Texas System Clinical Safety and Effectiveness Course Eric J. Thomas, MD, MPH; Jan Patterson, MD, MS; Sherry Martin, MEd; Doris Quinn, PhD; Gary Reed, MD; Ken Shine, MD | February 1, 2011  View more articles from the same authors. Citation Text: T…
  13. psnet.ahrq.gov/web-mm/isolated-clot-real-error
    December 01, 2013 - SPOTLIGHT CASE Isolated Clot, Real Error Citation Text: Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3…
  14. psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
    September 27, 2023 - SPOTLIGHT CASE Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation Citation Text: Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. Rockville (MD): Agency for Health…
  15. psnet.ahrq.gov/classics
    August 01, 2023 - Classics and Emerging Classics To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient sa…
  16. 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…
  17. psnet.ahrq.gov/web-mm/another-fall
    June 01, 2010 - SPOTLIGHT CASE Another Fall Citation Text: Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848107/psn-pdf
    April 26, 2023 - Improving Diagnostic Safety and Quality April 26, 2023 Al-Khafaji J, Lee M, Mossburg S. Improving Diagnostic Safety and Quality . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality Introduction During an annual editorial review of featured articles in the Agency for …
  19. psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
    February 26, 2025 - In Conversation With… Kaveh Shojania, MD November 1, 2015  Citation Text: In Conversation With… Kaveh Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…
  20. psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
    March 31, 2021 - SPOTLIGHT CASE Delayed Diagnosis of Mesenteric Ischemia Citation Text: Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …

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