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  1. Spotlight

    psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
    January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations  1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…

  2. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. | PSNet

    psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
    November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. Citation Text: Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…

  3. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. | PSNet

    psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
    July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. Citation Text: 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]. Rockville (MD): A…

  4. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. | PSNet

    psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
    March 03, 2021 - SPOTLIGHT CASE Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. Citation Text: Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…

  5. Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma. | PSNet

    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…

  6. In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
    February 26, 2025 - The National Action Plan specifies 17 recommendations centered on four priority areas to build the foundation

  7. Learning Health Systems for Patient Safety | PSNet

    psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
    February 26, 2025 - The National Action Plan specifies 17 recommendations centered on four priority areas to build the foundation

  8. Can Research Help Us Improve the Medical Liability System? | PSNet

    psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
    March 01, 2012 - The letter would summarize the issues in the case and the course of the case, but then include recommendations

  9. In Conversation With… Richard C. Boothman, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
    March 01, 2012 - The letter would summarize the issues in the case and the course of the case, but then include recommendations

  10. EMS Patient Safety in the Field | PSNet

    psnet.ahrq.gov/perspective/ems-patient-safety-field
    July 28, 2021 - care, the profession commonly utilizes medical protocols that guide responders through evidence-based recommendations

  11. In Conversation With… Jack Needleman, PhD | PSNet

    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…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866993/psn-pdf
    October 30, 2024 - In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances October 30, 2024 Salisbury-Afshar E, Gale B, Mossburg S. In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances. P…

  13. Psn-Pdf (pdf file)

    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…

  14. Dependence vs. Pain | PSNet

    psnet.ahrq.gov/web-mm/dependence-vs-pain
    October 30, 2019 - SPOTLIGHT CASE Dependence vs. Pain Citation Text: Gordon AJ. Dependence vs. Pain . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33866/psn-pdf
    September 01, 2018 - In Conversation With… Sigall K. Bell, MD September 1, 2018 In Conversation With… Sigall K. Bell, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md Editor's note: Dr. Bell is Director of Patient Safety and Discovery at OpenNotes, Beth Israel Deaconess Medical Center and As…

  16. Transition Coaches® Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs | PSNet

    psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
    March 27, 2024 - Transition Coaches® Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL June 12, 2020 Innovation Contact …

  17. Falling Through the Crack (in the Bedrails) | PSNet

    psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
    February 19, 2020 - SPOTLIGHT CASE Falling Through the Crack (in the Bedrails) Citation Text: Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation F…

  18. In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives | PSNet

    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  Also Read the Essay View more articles from the same authors. Citation Text: Helwig A, Sousane Z, …

  19. Health Plan Patient Safety Initiatives | PSNet

    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  Also Read the Conversation View more articles from the same authors. Citation Text: Helwig A, Sousane Z, Mossburg S. Health Plan Patient S…

  20. In Conversation with...David Marx, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
    October 01, 2007 - In Conversation with...David Marx, JD October 1, 2007  Also Read an Essay Citation Text: In Conversation with..David Marx, JD. PSNet [internet]. 2007.In Conversation with...David Marx, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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