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  1. Pitfalls in Diagnosing Necrotizing Fasciitis | PSNet

    psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
    March 24, 2021 - SPOTLIGHT CASE Pitfalls in Diagnosing Necrotizing Fasciitis Citation Text: Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867497/psn-pdf
    February 26, 2025 - Retained Surgical Items: Causation and Prevention February 26, 2025 Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention Background A retained surgical item (RSI) is a surgical patient safety pro…

  3. In Conversation With… Brian Jarman, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
    March 01, 2015 - In Conversation With… Brian Jarman, PhD March 1, 2015  Also Read an Essay Citation Text: In Conversation With… Brian Jarman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy…

  4. A Fatal Twist in Pseudohyperkalemia | PSNet

    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. Copy Citation Format: …

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850361/psn-pdf
    June 14, 2023 - Critical Echocardiogram Result Lost to Follow-up June 14, 2023 Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow The Case A 63-year-old man with history of stroke, systolic heart failure, and ventric…

  6. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness | PSNet

    psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
    February 01, 2014 - Would you recommend that when they get interrupted in the middle of a task, before they go in and see

  7. The Role of Graduate Medical Education (GME) in Improving Patient Safety | PSNet

    psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
    February 01, 2010 - The Role of Graduate Medical Education (GME) in Improving Patient Safety Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS | February 1, 2010  Also Read a Conversation View more articles from the same authors. Citation Text: Baron RB, Vidyarthi A. The Role of Gra…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73334/psn-pdf
    August 01, 2024 - An Inadvertent Bolus of Norepinephrine. May 26, 2021 Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…

  9. In Conversation With... Charles A Crecelius, MD, PhD, CMD and Lori L Popejoy, PhD, RN, FAAN | PSNet

    psnet.ahrq.gov/perspective/conversation-charles-crecelius-md-phd-cmd-and-lori-l-popejoy-phd-rn-faan
    October 28, 2020 - Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) recommend

  10. In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
    February 26, 2025 - Is there any one piece that you feel must be used by an organization or that you would specifically recommend

  11. The Evolution of Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/evolution-root-cause-analysis
    February 26, 2025 - Is there any one piece that you feel must be used by an organization or that you would specifically recommend

  12. Long-Term Care and the Response to COVID-19 | PSNet

    psnet.ahrq.gov/perspective/long-term-care-and-response-covid-19
    October 28, 2020 - Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) recommend

  13. An Inadvertent Bolus of Norepinephrine. | PSNet

    psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
    December 04, 2016 - SPOTLIGHT CASE An Inadvertent Bolus of Norepinephrine. Citation Text: Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation F…

  14. In Conversation with...J. Bryan Sexton, PhD, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
    December 01, 2006 - RW: In the patient satisfaction survey world, the question, "would you recommend this hospital"?

  15. Establishing a Safety Culture: Thinking Small | PSNet

    psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
    December 01, 2006 - RW: In the patient satisfaction survey world, the question, "would you recommend this hospital"?

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33715/psn-pdf
    July 01, 2011 - Becoming a Patient Safety Organization July 1, 2011 Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization Perspective While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49619/psn-pdf
    February 01, 2011 - Paradoxical Pulse February 1, 2011 Roy CL. Paradoxical Pulse. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/paradoxical-pulse The Case An 80-year-old man with paroxysmal atrial fibrillation and symptomatic bradycardia underwent successful pacemaker placement as an outpatient. The patient was restarted on …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33827/psn-pdf
    February 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS February 1, 2017 Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps Perspective Ten years ago, the Ag…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33735/psn-pdf
    August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It August 1, 2012 Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it Perspective At any point in time, …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49868/psn-pdf
    July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With Dementia July 2, 2019 Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia The Case An 86-year-old man with neurode…
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