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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.
Citation Text:
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - SPOTLIGHT CASE
Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.
Citation Text:
Graves CE, Kuhn MA. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - SPOTLIGHT CASE
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.
Citation Text:
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - SPOTLIGHT CASE
A Fatal Twist in Pseudohyperkalemia
Citation Text:
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
November 02, 2016 - Promising Areas for Patient Safety Research
P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH | December 1, 2003
View more articles from the same authors.
Citation Text:
Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. …
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psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
April 01, 2005 - Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet)
Robert M. Wachter, MD | April 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Ne…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - care providers can improve diagnostic safety through the use of relationship-based principles, e.g., promoting
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psnet.ahrq.gov/node/836850/psn-pdf
March 31, 2022 - Annual Perspective: Topics in Medication Safety
March 31, 2022
Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
Introduction
Issues with medication management and errors in medi…
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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/node/865373/psn-pdf
March 27, 2024 - In Conversation with...Patrick Tighe about Artificial
Intelligence
March 27, 2024
Tighe P. In Conversation with..Patrick Tighe about Artificial Intelligence . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
Editor's note: Patrick Tighe, MD, M…
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - SPOTLIGHT CASE
Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery
Citation Text:
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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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/perspective/conversation-lawrence-smith-md
February 01, 2012 - In Conversation With… Lawrence Smith, MD
February 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… Lawrence Smith, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
…
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psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
September 13, 2023 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use
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March 31…
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - SPOTLIGHT CASE
Missed Opportunities for Suicide Risk Assessment
Citation Text:
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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For…
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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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…