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psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
July 23, 2024 - Suicide Prevention in an Emergency Department Population: ED-SAFE
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April 24, 2024
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - Annual Perspective
Improving Diagnostic Safety and Quality
Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD
| April 26, 2023
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Al-Khafaji J, Lee M, Mossburg S. Improving Di…
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - Duplicate Therapies in Retail Pharmacy
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Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - SPOTLIGHT CASE
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Citation Text:
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - Patient and Family Roles in Safety
Beverley H. Johnson, FAAN, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD
| June 14, 2023
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Johnson B, Lee M, Mossburg S. Patient and Fam…
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm
Beverley H. Johnson, FAAN
| June 14, 2023
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Johnson B. In Conversation with.. Beverley H…
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - Primary Care and Patient Safety: Opportunities at the Interface
September 28, 2022
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In Conversation With... Freya Spielberg, MD, MPH
In Conversation With... Jack Westfall, MD, MPH
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psnet.ahrq.gov/node/838197/psn-pdf
September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a
Plan.
September 28, 2022
Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor
Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022.
https://psnet.…
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - SPOTLIGHT CASE
A Lot of Pain (Medications)
Citation Text:
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/sites/default/files/2024-04/spotlight_case_missed_connection-a_case_of_inadequate_ecg_oversight_in_cardiac_surgery_slides_-_final.pdf
January 01, 2024 - Spotlight
Spotlight
Missed Connection: A Case of Inadequate ECG
Oversight in Cardiac Surgery
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Christian Bohringer, MBBS, …
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psnet.ahrq.gov/node/865429/psn-pdf
April 24, 2024 - Missed Connection: A Case of Inadequate ECG Oversight
in Cardiac Surgery
April 24, 2024
Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac
Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery…
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer
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July 31, 2023
Innovation
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psnet.ahrq.gov/perspective/equity-patient-safety
September 24, 2024 - Annual Perspective
Equity in Patient Safety
Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD
| March 27, 2024
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Thomas A, Lee M, Mossburg S. Equity in Patient Safety. …
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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…
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - A Tale of Two Falls
Citation Text:
Jackson V, Satake A. A Tale of Two Falls. 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/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024
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Helwig A, Sousane Z, …
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psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - Health Plan Patient Safety Initiatives
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024
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Helwig A, Sousane Z, Mossburg S. Health Plan Patient S…
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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/perspective/patient-safety-frail-older-patients
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
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Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - In Conversation With... Heidi Wald, MD
November 26, 2019
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Citation Text:
In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.In Conversation With... Heidi Wald, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …