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  1. psnet.ahrq.gov/web-mm/its-sarah-not-stephen
    January 01, 2015 - SPOTLIGHT CASE It's Sarah, Not Stephen! Citation Text: Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…
  2. psnet.ahrq.gov/toolkits
    March 01, 2025 - Toolkits Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols. Want to submit a Toolkit? Has your organization deve…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847934/psn-pdf
    April 26, 2023 - Patient Safety Indicators April 26, 2023 Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/patient-safety-indicators Background Over the past 25 years, policymakers and providers, payers, and purchasers of health care have increasingly focused attention on pati…
  4. psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
    August 01, 2006 - Tacit Handover, Overt Mishap Citation Text: Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73455/psn-pdf
    June 30, 2021 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks June 30, 2021 Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks The Case At the…
  6. psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
    March 09, 2022 - SPOTLIGHT CASE Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis Citation Text: Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. …
  7. psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - The Role of Undergraduate Nursing Education in Patient Safety Joan Stanley, PhD, NP, FAAN, FAANP; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD | November 27, 2023  Also Read the Conversation View more articles from the same authors. Citation Text: Stanley J, Ga…
  8. psnet.ahrq.gov/perspective/zero-harm-striving-reduce-preventable-harms-point-counterpoint-and-areas-agreement
    September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement Carole Stockmeier, MHA, BS, Eric Thomas, MD, MPH, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD | September 24, 2024  Also Read the Conversations In Conversation with Ca…
  9. psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety Joan Stanley, PhD, NP, FAAN, FAANP | November 27, 2023  Also Read the Essay View more articles from the same authors. Citation Text: Stanley J. In Conversat…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73104/psn-pdf
    January 04, 2021 - For example, when hospitals provide patients with medical masks, require providers to also wear masks
  11. psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
    July 17, 2024 - SPOTLIGHT CASE Tough Call: Addressing Errors From Previous Providers Citation Text: Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy…
  12. psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
    July 10, 2024 - In Conversation With… Thomas J. Nasca, MD, MACP April 1, 2016  Citation Text: In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citat…
  13. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
    January 01, 2022 - Spotlight Spotlight Patient Safety Events Involving Opioid Dose Stacking Source and Credits • This presentation is based on the January 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73103/psn-pdf
    March 31, 2021 - Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination March 31, 2021 Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical Examination. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866992/psn-pdf
    May 29, 2024 - Harm Reduction Strategies to Improve Safety for People Who Use Substances October 30, 2024 Salisbury-Afshar E, Gale B, Mossburg S. Harm Reduction Strategies to Improve Safety for People Who Use Substances . PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-w…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865455/psn-pdf
    March 27, 2024 - Communication During Transitions of Care March 27, 2024 Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/communication-during-transitions-care Introduction Inaccurate or untimely communication and ineffective teamwork in healthca…
  17. psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
    June 15, 2024 - In Conversation With… Andrew Bindman, MD November 1, 2016  Citation Text: In Conversation With… Andrew Bindman, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation For…
  18. psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
    October 30, 2024 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission Save Save to your library Print Download PDF Share Facebook Twitter Linkedin C…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33740/psn-pdf
    November 01, 2012 - In Conversation With… Abraham Verghese, MD November 1, 2012 In Conversation With… Abraham Verghese, MD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-abraham-verghese-md Editor's note: Abraham Verghese, MD, is Professor for the Theory and Practice of Medicine at the Stanford University S…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/863308/psn-pdf
    February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy February 28, 2024 Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy The Case A…

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