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psnet.ahrq.gov/web-mm/always-check-muscle-twitch-residual-neuromuscular-block-after-removal-gastric-balloon
January 29, 2021 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon
Citation Text:
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness
Suzanne Beyea, RN, PhD | February 1, 2014
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In Conversation With… Enrico Coiera, MB, BS, PhD
In Conversation With… Richard Kronick, PhD
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH
September 28, 2022
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Citation Text:
In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.In Conversation With... Freya Spielberg, MD, MPH. PSNet [internet]. Rockville (MD): Agen…
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - SPOTLIGHT CASE
Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation
Citation Text:
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - Ensuring Patient and Workforce Safety Culture in
Healthcare
March 27, 2024
Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
Introduction
In 2020, the I…
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - Complications of ECMO During Transport
Citation Text:
Broman M. Complications of ECMO During Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA
April 1, 2010
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Citation Text:
In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - WebM&M: Case Studies
WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME/CPE . Commentaries are written by patient safety experts and published monthly. Have you encou…
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psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
March 15, 2023
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of
Gastric Perforation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/agitated-delirium-contributes…
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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 …
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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
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View more articles from the same authors.
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psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix
Leo A. Gordon, MD | September 1, 2007
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View more articles from the same authors.
Citation Text:
Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The…
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - The Safety of Medical Devices
Christopher Nemeth, PhD | June 1, 2011
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Citation Text:
Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test
Citation Text:
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings
Citation Text:
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - SPOTLIGHT CASE
Premature Closure: Was It Just Syncope?
Citation Text:
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety
Ronen Rozenblum, MD, MPH, and David Bates, MD, MS | November 1, 2017
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Citation Text:
Rozenblum R, Bates DW. The Role…
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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - In Conversation with...Lucian Leape, MD
August 1, 2006
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Citation Text:
In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006.In Conversation with...Lucian Leape, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…
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psnet.ahrq.gov/perspective/workplace-safety-health-care
January 01, 2017 - Workplace Safety in Health Care
Ross W. Simon and Elena G. Canacari, RN | January 1, 2017
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Citation Text:
Simon RW, Canacari EG. Workplace Safety in Health Care. PSNet [internet]. Rockville (MD):…
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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - SPOTLIGHT CASE
Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy
Citation Text:
Kelly KJ. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Resear…